Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 26 - Evidence - February 5, 2015
OTTAWA, Thursday, February 5, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day, at 10:27 a.m., to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie from Nova Scotia. I will ask my colleagues to introduce themselves, beginning on my right.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Enverga: Tobias Enverga from Ontario.
Senator Wallace: John Wallace from New Brunswick.
Senator Beyak: Senator Lynn Beyak, Dryden, Ontario.
Senator Nancy Ruth: Nancy Ruth from Toronto.
[Translation]
Senator Chaput: I am Maria Chaput from Manitoba.
[English]
Senator Merchant: Pana Merchant, Saskatchewan.
Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.
The Chair: Thank you, colleagues. We are continuing our study on the increasing incidence of obesity. We have a panellist who is supposed to be joining us via video link. That is being established from both ends as we wait. I want to get the meeting under way.
Mr. Jeffery has kindly agreed to make his presentation, and when Dr. Lustig comes on, I will briefly interrupt, welcome him to the panel and then have Mr. Jeffery continue and complete his presentation. Is that okay with the committee?
Hon. Senators: Agreed.
The Chair: Thank you very much. Mr. Jeffery, I invite you to make your presentation.
Bill Jeffery, National Coordinator, Centre for Science in the Public Interest: Thank you, Mr. Chair and committee members. I appreciate the opportunity to appear before the committee on this important topic.
I'm the National Coordinator of the Centre for Science in the Public Interest, which is a non-profit health advocacy organization specializing in food and nutrition issues. We don't accept funding from industry or government. We are fortunate to have a very successful newsletter, and I've circulated some copies of the most recent issue. We have about 100,000 subscribers in Canada, which works out to about one within a block of every Canadian street corner. It's only published in English, unfortunately.
I would say importantly that rates of obesity are symptomatic of a larger problem of diet-related disease. According to the World Health Organization, in Canada between 48,000 and 66,000 deaths every year are caused by nutrition- related heart disease, stroke, cancer and diabetes. There have been various estimates in Canada of the economic burden of sodium-related illness and obesity-related illness, and they all range in the billions, from $3 billion to $30 billion. The one common feature of all of these estimates is that they all say that they're conservative in their assumptions. So, in fact, the economic burden could be substantially higher.
As some of your previous witnesses have noted, life expectancy in Canada is rising, but we're noticing that there is a longer period of illness at the end of life. I think the objective for Canadian society and federal government policy should be to help compress that period of disability and illness at the end of life so we can have rich and full lives.
I'll talk a little bit about trends in dietary intake, and then I've made seven broad proposals for federal public policy changes. I'm happy to discuss them in greater detail during the question and answer period.
First, with regard to trends in food consumption, Health Canada and Statistics Canada have only really collected comprehensive dietary intake surveys twice in the past 40 years, in the early 1970s and again in 2004. The methodologies between those two studies were sufficiently different that it's difficult to compare the two numbers.
However, Statistics Canada does collect what they call food disappearance data, and they have collected it every year since about 1960. Since 1976, there have been roughly comparable data collection strategies, so you can observe changes in intake patterns, although only for the population at large. If you go to the Health Canada website and the CANSIM data set, you can see that during the 1990s, generally the period when obesity rates were rising in Canada, the average per capita daily consumption of calories gradually rose by about 240 calories. It had been stable between the 1970s and 1980s, and then it rose gradually for about a decade and then levelled off. You can see that mirrors very closely the changes in obesity rates.
So Statistics Canada says that rise in caloric intake came from 114 calories from fats and oil, 69 more calories from wheat flour and things it was used to make and 23 calories from soft drinks. After that, calories from soft drinks did decline slightly. There were some rises and falls in consumption of other commodities, but they generally offset each other.
It is settled ground, I think it's fair to say, among health scientists and public health authorities that Canadians consume too many calories, too much sodium, too much refined grains, too much free sugars, which is sugar that's added to food but also sugar that is found in fruit juice because the nutritious part of the fruit is removed, and also too much red and processed meat and too little non-starchy fruits and vegetables, too little whole grains and too little legumes, such as nuts and beans.
Now, I know there has been some discussion earlier in this committee about the relative contribution of physical activity and nutrition, and I think it's fair to say there is some information in my report indicating that most of the weight gain during that period in the 1990s is explained by increases in caloric intake, not decreases in physical activity.
So there are seven general public policy reforms that we recommend. I'm happy to talk about these in greater detail later. They're all supported, I think, by pretty solid scientific research and expert opinion.
The first is front-of-package nutritional labelling. There are some changes that should be made to the nutrition facts table, but it is on the back of the label, and that actually makes a huge difference in the effectiveness of nutrition labelling.
With respect to restaurant menu labelling, restaurants have been exempt from mandatory nutrition labelling since their inception in Canada a decade and a half ago. More than 40 groups across Canada are calling for sodium and calorie information to be reported on restaurant menus on a mandatory basis, at least large chain restaurants.
With respect to food tax reform, the federal government alone collects more than $3 billion from taxes on food. That's taxes in restaurants that are applied indiscriminately, whether it's for steamed broccoli or poutine. Also, interestingly, at the grocery store, if you buy fruit salad in the produce section, that's taxed in most provinces at 13 per cent, but if you buy a box of Froot Loops, that's exempt from tax. There are many other examples, but that illustrates the point.
With respect to sodium reduction, there are some links between sodium consumption, although it doesn't actually have calories by itself, but the consumption of sodium contributes to that bliss point that other witnesses may have spoken about, which makes the food more appealing and there's also some evidence to indicate that salty food promotes consumption of sugar-sweetened beverages, which can increase the caloric load.
Anyway, the Minister of Health appointed a Sodium Working Group several years ago. I was a member of that, along with 24 others from all sectors with a stake in this, and they made unanimous recommendations for reducing the sodium level in the food supply, which really have not been followed. There are more details about that in my technical brief.
There has been some movement in reducing trans fat in the food supply. Those successes should be locked in with regulations. I know in the United States there is some evidence to indicate there were reductions in trans fat and saturated fat levels in movie theatre popcorn in the 1980s as a result of public pressure, but when the pressure came off, the saturated and trans fat levels went back up. So we really need to make sure there's a binding legal requirement.
Doubtless, some of your other witnesses have talked about restricting advertising directed at children, as Quebec has done, and we certainly think that's a good idea. It's really tricking children. It's legalized tricking of children, as they're unable to properly interpret this.
Finally, I think Canada may be one of the very few large industrialized countries without a national school meals program. We have a kind of hodgepodge of very poorly funded provincial programs and at least a couple of municipal programs with contributions from non-governmental organizations. Whereas the United States federal government spends about $1.50 per student per day, we spend a little bit less than a nickel per student per day here, and it's really not enough to sustain a good school meals program.
Those are my general comments. The only thing that I would add is that there is a temptation amongst some to assume that there's a lot of confusion about what is true from a nutritional standpoint, and I think a lot of that confusion is created by people with a financial stake in it. If you are hearing a hypothesis about nutrition that doesn't seem right to you, I think you should ask whether that squares with what the World Health Organization, the U.S. Institute of Medicine and Health Canada would say.
The Chair: Thank you, Mr. Jeffery. I'm now going to recognize the arrival of Dr. Lustig with us via teleconference. We had begun, as you can tell, doctor, and I'm now going to invite you to make your presentation. The clerk has advised you as to the length of time you have. At five minutes I will signal, and following your presentation, we will open the floor to questions from senators.
Welcome. We thank you very much for joining us. I'm now going to ask you to make your presentation, please.
Dr. Robert Lustig, Professor, University of California, San Francisco, as an individual: Thank you very much, Senator Ogilvie. Thank you all for having me and inviting me to this very important discussion. I have three things to say. I'll try to make them as brief as I can, but you have to understand that there is science behind all of this. There are three myths that have to be debunked in order to be able to move this entire issue forward for the future for the health of our children. These three myths are promulgated very specifically by the food industry and have been for the last 45 years. We have basically swallowed all of these hook, line and sinker. Until these three myths are debunked, we will not be able to extricate ourselves from this problem.
The first myth is that this is about obesity. Indeed, they want it to be about obesity because many, many different foodstuffs cause obesity or cause weight gain. Numbers one and two are potato chips and french fries. Sugar-sweetened beverages and sugary desserts and other things containing sugar are third down the list. If it's not about obesity, what is it about? It's about the metabolic dysfunction that actually causes the obesity. Let me put it to you this way. Everyone thinks that it's the obese person's fault because 80 per cent of the obese population is metabolically ill, but what that means is that 20 per cent of the obese population is metabolically healthy. They will live a completely normal life, die at a completely normal age, not cost the taxpayer a dime. They're just fat. Conversely, let's look at the normal weight population. It turns out that 40 per cent of them have the exact same metabolic diseases and the exact same metabolic markers as do the obese. They get type 2 diabetes. They get hypertension. They get lipid problems. They get heart disease. They get cancer. They get dementia also. They get it at a slightly lower prevalence — 40 per cent instead of 80 per cent — but there are more of them.
If normal weight people can get this, too — and it's called metabolic syndrome; you've heard of it — then how can it be about behaviour? In fact, when you look at the pattern of spread, when you look at the groups involved, this actually looks more like exposure. This looks more like tuberculosis or cholera or HIV or some other infectious agent. It's not infectious, but it's an exposure that even normal weight people are exposed to. So the question is: What is that exposure? That's the first myth to be debunked, that it's about obesity. They want it to be about obesity because, if it's about obesity, it's gluttony and sloth. You are what you eat; if you're fat, it's your fault; diet and exercise; go pick on somebody else's calories. It fits all of the mantras that the food industry has promulgated over the past 45 years. It's not true.
The second myth is that a calorie is a calorie. If a calorie were a calorie, then the amount you would eat and the amount you would burn would always be in relation to each other, and, of course, obesity would mean that you ate too much and exercised too little. Therefore, it's pejorative. Therefore, it's a behaviour. Therefore, it's your fault. Not true. It's completely mythological. There's this phenomenon, this discipline called nutritional biochemistry. It's what I majored in in college, and I knew all of this back then. In medical school, it was all beaten out of me. A calorie was a calorie. Basically, it came back to me about one decade ago that I actually knew all of this way back when. In fact, a calorie is not a calorie. Where those calories come from determines where they go in the body and what diseases they cause. Nowhere is that more obvious than with sugar. Sugar, because of its very unique metabolism in the liver, causes all of the diseases downstream that we now refer to as metabolic syndrome, and there are numerous meta analyses, clinical research, substitution analyses and randomized controlled trials that demonstrate this phenomenon. We have just completed one here at UCSF that is basically going to blow the rafters off when these data are released in about three months.
Myth number three: It's about personal responsibility. Personal responsibility has four caveats. Number one, you have to have knowledge. You have to know what you're doing in order to exercise personal responsibility, and right now the American population, the Canadian population and, really, the international population do not know what they're doing. There are several reasons why. The information is actually being withheld from them. The first piece of information is that there are 56 names for sugar. They're all used on the label. Because the ingredients are listed in order of mass, you can have a different sugar as number 5, number 6, number 7, number 8, number 9, and, when you total it up, it's number 1. You're not allowed to know that. Plus, they only list total sugars, not added sugars. For instance, yogurt has seven grams of lactose, which is milk sugar, which is perfectly fine, but a fruit-flavoured yogurt has 23-grams of sugar. That means that, when you consume a fruit-flavoured yogurt, you're consuming a plain yogurt plus a bowl of Captain Crunch. Nobody knows that. That's specifically withheld from the consumer.
On the nutrition facts label that we currently use, there is a dietary reference intake, a per cent for every single nutrient on that list except for one, and it's sugar. That's very specific because the food industry doesn't want you to know how much is too much. If you knew how much was too much, breakfast cereal would disappear from the planet in a nanosecond. You have to have knowledge.
Second, you have to have access, and our poor people and people in First Nations, where they're getting their food as subsidies from government programs, do not have access. They do not have access to rational, healthy food. They only have access to what is given to them, and what is given to them is cheap.
Third, you have to have affordability. You have to be able to afford your choice, and, right now, the amount of money that the food industry makes in profit here in the United States, at $450 billion a year, is so dwarfed by the amount of money that is spent in health care costs for chronic metabolic disease and that could be recouped if we could solve this — $1.4 trillion. In other words, we spend three times as much as they make. This is unsustainable, and that is why, here in America, Medicare will be broke by the year 2026. We just can't afford this choice.
Fourth, your choice can't affect anyone else. That's called externalities. So if you smoke, it's bad for me. If you drink, it's bad for me. If you take street drugs, it's bad for me. If you eat sugar containing foods, if you drink sugar- sweetened beverages, is that bad for me? This goes to the whole question of whether or not society has a role in trying to do something about it. The answer is clearly yes, it is bad for me because there won't be any health care, because there won't be any doctors and because you won't be able to get into an emergency room for all of the coronary stents that they will be placing, for all of the dialysis that they'll be doing and for all the diabetes that they will be taking care of in our teenagers. That's what is happening. It's happening now, and those three myths are standing in the way of any rational societal action. When those three myths are debunked, you can see that what we need to do is to reclassify sugar, in particular, away from food, which it is right now, at 18 per cent of our diet, back down to food additive, when it was 4 to 5 per cent of our diet, which is what the World Health Organization has called for. I support it completely.
The Chair: Thank you very much, doctor. I decided not to interrupt you in the flow. It was tremendously interesting. Thank you very much for the presentation.
I'm now opening the floor to questions from my colleagues.
Senator Eggleton: So we should change the name of this study from a study on obesity to a study on metabolic syndrome, I take it, Dr. Lustig.
You're particularly focusing on sugar. You're saying sugar is the enemy here, particularly the industry that puts it in.
Dr. Lustig: There are four enemies in our diet, but sugar is by far and away the most prevalent and the most egregious and the one that the food industry adds for its own purposes. Let me list the four enemies of our liver metabolism.
First, trans fats. But we knew that, and they're coming down.
Second, branched-chain amino acids. These are the amino acids leucine, isoleucine and valine. These are dietary amino acids, amino acids that are in meat and milk and many other sources, but they are at relatively low levels except in corn-fed animals. You need leucine, isoleucine and valine to help build muscle. If you're a body builder you take protein powder to build muscle and if you're building muscle then these branch chain amino acids are good. But if you're not building muscle and you consume an excess of them, what happens is that that excess goes to your liver. It gets broken down and creates the same problem with liver fat as sugar.
Third, alcohol. But kids don't drink alcohol.
Fourth, fructose, which is the sweet molecule of sugar.
Those are the four that are particularly egregious for this problem of metabolic syndrome. These four, trans fats, branch chain amino acids, alcohol and sugar constitute the processed food diet in America, in Canada and around the word.
The reason these four are so egregious is that they share three things in common. First, only the liver metabolizes them; second, they are not insulin regulated; and third, they overwhelm the liver's capacity to metabolize it and the liver has no choice but to turn the excess into liver fat. That liver fat then drives all of the downstream negative consequences of all of these metabolic diseases, including insulin resistance where your pancreas has to make extra insulin and that drives the weight gain. In other words, obesity, the rate of weight gain that you are so worried about is actually a consequence of the problem of the fatty liver that these four substances are causing.
The problem is that sugar is the marker for processed food. Sugar is the foodstuff that the food industry uses specifically as its hook to get you to buy more. So it's not that sugar is the only problem, it's just the most amenable problem.
Senator Eggleton: So you partly answered the question I was about to ask. Let me also ask you about sodium in terms of its effects on the body, the diseases it creates and obesity connections.
Dr. Lustig: The salt issue is extraordinarily complicated and it depends on who you ask as to what answer you get. If you look at the meta-analysis of sodium consumption and cardiovascular disease and diabetes, what you see is there is an effect. But the effect is a hazard risk ratio of 1.24 to 1.27. What that means is that if you increase your consumption of salt you are 24 to 27 per cent more likely to develop a heart attack or stroke. That is a big number, except for one thing. The scientists, the people who do this for a living, the statisticians, have actually set the criteria for any societal intervention at 1.3. Now, when you look at the data on salt, what it shows is that there is a very specific population, perhaps maybe 15 per cent of the total population of Canada and the United States that are exquisitely salt sensitive. These people need to have their sodium consumption reduced. I do not argue that. I am absolutely in favour of it.
However, the majority of people, if their sodium consumption were reduced it would not affect their risk substantially because their kidneys can process that excess sodium at a better level than these other people, so they can actually manage the salt storm — the overflow that we currently have.
The question that your committee has to deal with is: Do the needs of the few outweigh the needs of the many? That's not a question that I can answer for you. That's a question that your committee has to take on as to whether or not it makes sense.
Now, as a physician, there's no reason anybody needs more than 2.3 grams of sodium in a day. The fact that we are consuming 6.9 grams of sodium is ridiculous and egregious. So personally, I am for reduction of salt. However, I do not want you to walk away thinking that if you reduce salt then you would be able to solve all of these problems because that's just not what the data show.
Senator Eggleton: I understand that. We talk about the bliss point that the industry tries to reach. It uses salt as well as sugar. If you entice people with the salt then they're going to get more sugar.
Dr. Lustig: From that standpoint, absolutely. But we were just talking about salt as its own issue. We were talking about processed food. Anywhere you find salt, you find more sugar. This is extraordinarily important.
If you go back to the YouTube video that I put out back in 2009, called "Sugar: The Bitter Truth,'' I very specifically had a slide, and I meant this and I still mean this, and the slide was titled the "Coca-Cola Conspiracy.'' What I talked about was the fact that there were 55 milligrams of sodium in a can of Coca-Cola. I asked the audience: Why is that salt there? Is it necessary? It's absolutely not necessary. You may remember when we were kids there was a soda called Royal Crown Cola. Royal Crown Cola had no salt. You did not have to put salt in soda. The reason for the salt is because it makes you urinate more because when your kidney is getting rid of it, it takes water with it. That makes you thirstier.
Senator Eggleton: Sorry, my time is just about up. I haven't had a chance to ask Professor Jeffery anything. I'll get him on the next round.
Do you hold out any hope that there can be negotiations with the industry that developed this bliss point that processes this stuff in the way they do nowadays to get more and more revenues, more and more customers? Do you see any hope in a negotiation with them or is it going to require government legislation?
Dr. Lustig: I'm going to be very honest with you. You will not be able to negotiate a settlement with the industry. What you will be able to do is bring industry to the table with certain precepts that will ultimately be adopted and made to work by everyone because the government will set the playing field. Then the industry will decide how they individually want to solve that.
This is what happened in the U.K. Due to the political action committee, action on salt, as led by Dr. Graham MacGregor of the Wolfson Institute back in 2006, they pressured the Blair government to bring the entire British food industry to the table. What they said was you are going to wean the entire British population off salt and you're going to do it slowly, by 10 per cent a year, over the course of the next five years. How you do it is your business, but we're going to monitor it and we're going to play referee and you're going to do it. Guess what? They did it. Just six months ago there was a paper in the British Medical Journal showing that the incidence of heart disease and stroke in Britain was down by 40 per cent over that period of time because the government played referee and said we're going to make you do this. How you do it is your business, but yes, we are going to make you do it. There's no negotiation; will you do it, will you not do it? You have to say that yes, you will do it. Then they will say, okay, now let's figure out how we'll do it. That's the negotiation.
The Chair: Mr. Jeffery, I think you wanted to make a comment on one of the earlier responses?
Mr. Jeffery: I had a couple of points about the sodium issue. It's fair to say that others hold a different view on sodium. The World Health Organization has characterized population-level sodium reductions as the most effective way of reducing death in the world, rivalling even tobacco reduction. We have made efforts to try to get the Sodium Working Group recommendations implemented in Canada. In my 20 years of doing this I have never seen such an outpouring of support from health related NGOs. I think there were 70 groups that either lived in or served people who lived in two thirds of Canadian households that were in favour of this. We can't treat 6 million people who are sodium sensitive. There's no real laboratory technique for observing all of those people. There are some benefits in terms of blood pressure reduction that even accrue to people who are not sodium sensitive.
Senator Seidman: Thank you to both of you.
There's no doubt that this is a complex field and that it's continually in a state of flux. That's clear. Most people are pretty confused about what they should and shouldn't do. However, there is some evidence that's indisputable, and I think, Dr. Lustig, you made a very compelling argumentation for that. Mr. Jeffery, you did the same.
As we're legislators, obviously we're primarily concerned with the pragmatic aspects: What can we do to change things? What recommendations can we make? That's the point of this study: What recommendations can we ultimately make to change the health of Canadians?
I appreciate, Mr. Jeffery, your clarification about the changes in consumption patterns and the type of data that we collect or don't collect, and the fact that the consumption pattern changes mirror obesity increase. I think that's important to note.
But I would like to ask both of you one basic question. Mr. Jeffery, you have presented a list of recommendations for policy changes that is pretty impressive. Dr. Lustig, you have referred very clearly to policy issues and changes that are possible. What I'd really like to know is what policies do you think are likely to work, and why would they work? Because there is a host of things we can consider, but we should really consider, to be taken seriously, what could actually work — so pricing, marketing, distribution. The U.K. is trying things. Mexico is trying a soda tax. There are lots of things we can do. I'd like to hear from you what you think could work, and why.
Mr. Jeffery: Senator, I recommended things that I think will work in our technical brief. I think providing more useful information for consumers so that they can distinguish the wheat from the chaff can be very useful. That's not just on restaurant menus but also on the fronts of food packages.
This is critical. If you're walking down the aisle in a grocery store and you want to get some soup, and there are 30 or 40 different types of soup, if you want to find the one with the lowest amount of sodium, you have to pick up 30 cans and line them up on the shelf and then scan the information on the back of every label. That will take you a few minutes. If you're very studious — I've never seen anyone do this but me, frankly, and not for the weekly shopping but for some report that we're doing. To do that diligently, it would turn a shopping trip into a six-hour odyssey. It simply can't happen.
If you used the innovation from the United Kingdom, the traffic light system with red, yellow and green lights, and married that with the NuVal system from Yale University that rates all foods on a scale from 1 to 100 — so you could see that one soup might be 40 in the yellow, and the other one might be 60 or 62 or something — it makes it a simpler choice. You can spot it just by looking at the shelf, and likewise for the menu labelling.
With regard to food tax reform, it's insane, some of the policies we have. Froot Loops, exempt; fruit salad, taxable. Club soda is taxable. Bottled water is taxable, depending on the size. All of these rules were created at a time in Canada when nobody paid any heed to nutrition-related illness, and so they were made for other reasons.
We've already talked about sodium reduction. There's a fairly well-thought-out strategy that included input from public servants but also from industry and health-related groups. There's a growing consensus among child protection advocates that getting rid of advertising directed at children, as Quebec has done long ago, makes a lot of sense. The Supreme Court of Canada, in fact, has said that advertising directly to children is inherently manipulative.
Dr. Lustig: I agree with everything that Mr. Jeffery said, except for one, and I want to challenge him on it. He brought up a specific dietary evaluation system called NuVal. That is a proprietary, patented system developed by Dr. David Katz at the Yale-Griffin Prevention Research Center for his own he purposes and has no base in reality.
I'll give you an example of how it works. Basically, it gets points for things that are good and takes away points for things that are bad. If a foodstuff has toxin A and antidote B, is it good for you or bad for you, Mr. Jeffery?
Mr. Jeffery: The appeal of the NuVal system is that it's a rating scheme that goes from 1 to 100 on a scale. Some of the other types of front-of-package labelling schemes just give a check mark. So if it meets certain nutrition criteria —
The Chair: We're not going to get a long debate between the witnesses. Could you answer the question he asked?
Dr. Lustig: If a foodstuff has toxin A and antidote B, is it good for you; yes or no?
Mr. Jeffery: Since you put it that way, it's illegal to sell food with toxins in it, so it's not a food if it has a toxin in it.
Dr. Lustig: Guess what? We're selling foods with toxins all the time. There are 10,000 items on the Generally Recognized as Safe list. Do you really think those items belong there? Any item can get on to the GRAS list. All you need is a company to say so. Do you really think that those —
The Chair: We get it. The issue here for us — this is not going to be a debate. We want the points made. We are capable of following up. That system isn't used here, so I'm going to stop that one right there. Nothing further on that point.
Your next point.
Dr. Lustig: Aside from that, I agree with everything that Mr. Jeffery said.
The Chair: Thank you very much.
Dr. Lustig: In terms of things that can work, I totally agree that marketing to children is disingenuous and is a major issue. However, education has not solved any other substance of abuse. If we limit our interventions to education alone, we will not be successful in this. The question is: What other things do we have to do? Education is necessary but not sufficient.
Taxation is low-hanging fruit. Taxation is easy to implement. Everyone is talking about taxation. The question is: Does taxation work? The answer is that it depends on how big the tax is.
When you look at price elasticity, which is the measure of whether or not people still consume any given foodstuff when you raise the price, the price elasticity on a soft drink is extraordinarily high, meaning that people keep doing it. The reason is because sugar is addictive.
So trying to use taxation to reduce addictive substances, you have to make the tax hurt, and that's what we've learned with cigarettes. We're now at $12 in America for a pack of cigarettes. Yes, it is hurting because that number is very large. The question is: Are people ready for that? The whole question of taxation is a very difficult one.
The second thing that I think makes the most sense, and what we have actually looked at from the standpoint of alcohol and the relation between sugar and alcohol — because they're very similar in terms of their biochemical properties, their hedonic properties and also how they're marketed, and it's the chapter that I sent to Ms. Richardson last night that I hope you'll all have a chance to look at — is looking at the alcohol experience and how that can apply to sugar.
The thing that I think makes the most sense is differential subsidization — that is, not carrot, not stick; carrot and stick together. When you yoke the two together, that's when good things happen.
For instance, I'm not suggesting this is good, but if we subsidized diet soda and taxed sugared soda, you would get people to consume more diet soda. If we subsidized bottled water and taxed soda, you would be differentially subsidizing and therefore you would basically reduce the amount of the offending agent and get people to consume more of the thing that you want them to. You could subsidize broccoli and cauliflower and then tax processed foods. This has been actually suggested by many people in the field as the best way to go about this, but of course that takes a very large referendum and agreement in all halls of Ottawa.
Senator Merchant: I think there is confusion about foods because there's so much information out there, and I don't know how much of it is accurate. We know much of it isn't. I think education is important. It's one component, though. A lot of the education we get may be from advertisers, television. It may not be from journals that are scientifically correct.
There's a lot of talk about, for instance, glycemic index of foods. I would like some comments on that. If I could pose my second question for brevity, so we move on, there's a move now away from drinking milk and different kinds of milk, like coconut milk and soya milk. I know people buy it. I just read a report the other day about lower sales of milk. Could you comment on those two things, please?
Dr. Lustig: The concept of glycemic index has been taking the world by storm. I certainly understand glycemic index. Let me explain it to the people on the committee quickly.
Glycemic index refers to how high your glucose rises if you consume 50 grams of carbohydrate in a certain food. I think glycemic index is a canard, and I'll explain why. Let's take carrots. Carrots have a very high glycemic index. If you consume 50 grams of carbohydrate in carrots, your blood sugar will go pretty high. The question is: How many carrots do you have to eat to get 50 grams of carbohydrate in carrots? It turns out you have to eat 1.3 pounds of carrots. No one is going to do that.
What carrots demonstrate is a high glycemic index, but low glycemic load food. Glycemic load is really the thing that matters, not glycemic index, because you have to take into account the volume of food you have to consume because of the fibre. In other words, any food that has high fibre will, by definition, be a low-glycemic load food and thereby raise your blood glucose much less.
In other words, if you take any food in its natural state — because all food comes with its inherent fibre — real food is low-glycemic load food. I am for real food because of that. Glycemic index is a canard because, number one, you wouldn't eat carrots, and number two, do you know what the lowest glycemic load food is? It's sugar, because the fructose molecule doesn't get measured in the blood glucose, because fructose is not glucose. Fructose does not raise your blood glucose; it raises your blood fructose, and fructose binds inside your arteries to the proteins and actually causes the proteins to stop being flexible, and that's one of the reasons for atherosclerosis and hypertension. You can actually see the molecules of fructose binding to it using special antibody techniques.
So do you really want to be raising your serum fructose level? No, you don't. That would be the single worst thing you could do. Yet, the glycemic index proponents say that sugar is good. This is a canard. This is a move by the European Food Safety Authority to try to get sugars basically put into the food supply, which is what they did in 2013, and I am absolutely staunchly against it.
The Chair: Thank you. That was a very clear illustration for us.
Mr. Jeffery: One thing I would add to that is that the contribution that glycemic load or glycemic index makes to describing most foods is diminished by the fact that most feeds are multi-ingredient. You would only be using this glycemic load or glycemic index in relation to one of the ingredients in it. What proportion of the total food is that ingredient? It becomes a multiplier by a multiplier, so it increases the complexity and I think underscores the importance of having front-of-package labelling that gives an overall nutritional assessment of the food on a scale from 1 to 100. Obviously, you would want good nutrition criteria for calculating that.
Senator Merchant: I had a question about the turning away from milk to the other milks that are now very popular.
Mr. Jeffery: Some people are lactose intolerant and they choose those and try to get their source of calcium or vitamin D from those products. It's not something we recommend wholeheartedly. There are a lot of nutrition issues that are dwarfed by the big picture. We should be consuming more fruits, vegetables and whole grains and less free sugars and sodium and refined grains.
Dr. Lustig: There are two issues with respect to milk. One is the saturated fat issue and the other is the lactose issue. Mr. Jeffery nicely talked about the lactose issue. Yes, there are many people who are lactose intolerant and they do need to stay away from items containing lactose. Now there are lactose-free milks and I think there's enough play in the market that this problem is basically taking care of itself, so I'm not particularly worried about that.
The big issue with milk has been the saturated fat question. Milk has been one of the targeted items, along with eggs and meat, for many years, for 40 years, as being one of the things that promotes heart disease. There's new research now and the new research says something entirely different.
There are two kinds of saturated fat. There's the saturated fat that comes from meat, which are even-chain fatty acids, and there are the saturated fats that come from milk and dairy, which are odd-chained saturated fats. They are not the same. It turns out that the even-saturated fats and the odd-saturated fats are metabolized differently. The odd- chain saturated fats have a different phospholipid signature. When you do the empiric studies, which have now been done by Dr. Dariush Mozaffarian, who is now the Dean of the School of Nutrition at Tufts, it turns out that the dairy saturated fats with this different phospholipid signature are actually anti-inflammatory rather than pro-inflammatory.
Red meat, with its even saturated fat content, may still have some inflammatory properties. There are potentially ways to reduce that — for instance, grass fed beef — but milk appears to be on the other side and may in fact be anti- inflammatory.
With the exception of people who are lactose intolerant, I think milk is one of the best things that has been put on the earth. This China study that people refer to as being such an issue, with casein being the thing, those data have never been supported in any other venue. That is a set of univariate linear regression analyses that do not take into account the multivariate nature that has to be done with macronutrients. It is also one snapshot in time, not over time. I discount the China study until they do the study correctly, and they haven't done it correctly. I personally think milk is fine.
Senator Enverga: Thank you for the presentations, gentlemen. I think we have had really excellent presentations today and excellent witnesses.
Dr. Lustig, I think you will remember this very fondly. Over a decade ago, the World Health Organization caused a storm by mentioning that healthy diets should only contain 10 per cent of added sugar in our daily intake. However, the U.S. Sugar Association said that it should be 25 per cent of added sugar in our daily intake. This is a corporate action.
The question is: Did it work, or is there really a daily recommended intake of sugar? If there is, what is it?
Dr. Lustig: This is a question, of course, that is quite near and dear to my heart. We have sugar documents now that we are analyzing here at UCSF. My colleagues are doing this in the same way they did with the tobacco documents, to find out what the industry knew and when they knew it.
Here's what I can say, based on what we know today: The Institute of Medicine determination back in 2004 that said that dietary sugar could be up to 25 per cent of the diet of Americans, which the food industry continues to quote today, was manipulated from the inside by several food industry concerns that were allowed to sit at the table.
This is now being called into question — the Dietary Guidelines for Americans. The Dietary Guidelines Advisory Committee, DGAC, has submitted to the U.S. Department of Agriculture that they disagree with that assessment and that it should be no more than 10 per cent of total calories. Whether the USDA will accept that recommendation from an advisory group, which has no teeth, has yet to be determined. The DGAC is now on record officially as recommending 10 per cent or less.
The American Heart Association, and I helped contribute to the report, said six to nine teaspoons of added sugar per day, which comes to about 8 per cent. The World Health Organization has said 10 per cent, but try to move toward 5 per cent because of the incidence of dental caries, which is the greatest chronic disease and determiner of chronic pain in the world. So, 10 per cent for health and 5 per cent for teeth, is basically what they said.
I personally think that 10 per cent is a rational, achievable and consistent number that can be reached and monitored, but 8 per cent is good. I signed up for that with the American Heart Association. The questions are: What do you feel comfortable with? What do you think can be done? Is there a number that should be achieved? The answer is absolutely yes, and 25 per cent isn't it.
Mr. Jeffery: The American Heart Association arrived at this recommendation by using the 25 per cent figure from the U.S. Institute of Medicine and applying it to the diet that was recommended by the IM and the dietary guidelines in the United States. A lot of sugar is naturally occurring in fruits and vegetables and some grains and low-fat dairy. They found that if you deduct that basically recommended sugar that's intrinsic to certain foods, you're left with what they call discretionary sugar, which is the six to nine teaspoons a day — consistent with what the World Health Organization is saying.
The Chair: Dr. Lustig, are you recommending 10 per cent as total sugar?
Dr. Lustig: No, that would be added sugar.
The Chair: You're referring to added sugar. That's an important clarification. Thank you.
Dr. Lustig: I couldn't agree more. This is part of the issue. We really need to distinguish between endogenous sugar and added sugar. Endogenous sugar is not a problem because it comes with its inherent fibre. In milk sugar, the galactose is normally converted to glucose in the liver immediately. It's a non-issue too.
The Chair: We understand that. It didn't come out in the answer, so I wanted to be absolutely clear. It's a very important distinction. Mr. Jeffery, you wished to finish your comment.
Mr. Jeffery: For greater clarity, the World Health Organization's recommendations are about free sugar, which is essentially sugar extracted from naturally occurring things and added to other foods as an ingredient, added sugar, and also includes sugar that's in fruit juice — in fruit, where the healthy parts of the fruit are extracted. That's very important. Fruit juice is a major source of sugar that a lot of dietitians are concerned about.
Senator Enverga: My question is for Mr. Jeffery. You mentioned here a while ago on your list about marketing to children and labelling. We were talking before about making labelling more consistent or more geared to people who don't like to read all the mumbo-jumbo on labels. One idea would be symbols. For example, a can of beans could show a mouse, or a pig, or a whale. That's one thing we could think about to make labelling simpler, especially for kids.
Mr. Jeffery: First, I want to be on record as saying that I don't like the pig/mouse example, but I do like the sentiment of having visually clear symbols on the front of the package, which is critical. There's one important point. I emphasized before that having a scale of 1 to 100 is critical because it allows you to compare foods anywhere in the grocery store. If you have a symbol, a yes or no thing, you'll see that all over foods in the produce section and you won't see it on any foods in the cracker or soup section. And that's where you need help distinguishing the less nutritious ones from the more nutritious ones. Something on the front of the package, a rating scheme using colour coding makes sense but it should be on all foods, not just on some foods.
Dr. Lustig: I couldn't agree more. The traffic light diet, stoplight delineation, on the front of packaging would make a hell of a lot of sense. You have to determine what those criteria would be. Presumably those would be done in the halls of Parliament not in the halls of the food industry. You saw what happened with the smart check debacle, where Froot Loops became a healthy food. There's got to be a little consistency and a few feet to the fire when you do this. Front-of-packaging makes a lot of sense.
For the added sugars, we should be putting the number of teaspoons on the front of packaging, because that's what people understand. If they saw nine teaspoons of sugar on the package, they would think significantly about whether they want to put that item in their cart.
Mr. Jeffery: I'm sure the members of the committee know that Health Canada is considering changing the way nutrition information is represented on food labels. I understand from Minister Ambrose's early consultations with parents that there should be interpretive information on the front of the package for all the reasons we've been discussing. That isn't in the proposal circulated last September and this is a real problem. I'm concerned that while 48,000 to 66,000 people are dying every year from nutrition-related illness, we're proposing tiny tweaks to the backs of packaging. That will not make a significant dent in the death rate.
Senator Enverga: I mentioned to some communities that we're studying obesity. People have been saying, yes, you want people to eat healthy diets. However, you're not making it affordable. Is subsidy an answer to this to make fish and vegetables cheaper? It has to be a big boost to our healthy living.
Mr. Jeffery: There is a benefit, as Dr. Lustig was saying earlier, in using the carrot and the stick subsidy. You have to be careful about the way the subsidies particularly are applied because they could be sopped up by the intermediaries in the food supply chain. One key thing is that the beauty of a tax is if it's clear to Canadians that a food is being taxed because it's considered by the government to be less nutritious than another food, if that's indicated on the label and not just at the checkout counter in the grocery store, then it has an information aspect as well, which can amplify the effectiveness of those kinds of measures.
The Chair: Mr. Jeffery, you presumably have a copy of the Health Canada document you referred to with regard to the recommendations.
Mr. Jeffery: Yes. There are five documents.
The Chair: Could you send that or a link to the clerk of the committee? Thank you.
Senator Merchant: There are so many comparisons made with tobacco and how we attacked the harmful effects of tobacco. Now we are at the point where we have pictures on packaging, which is supposed to deter people from subjecting themselves to that kind of fate. Do you see that we may have to go that way or do you think that these other recommendations you're making, the colour coding, will suffice? We're hoping they will but if you look forward to the future do you see that we may have go to that very overt kind of packaging?
Dr. Lustig: Senator Merchant, I'm going to reiterate something I said earlier. Education alone has never solved any abuse of substance. I would argue there's plenty of data that shows that those grotesque, horrible pictures that have been put on cigarette packs — showing people with tracheostomies and missing half their lungs and half their tongues — has not done anything to stem the tide of cigarette consumption. When you look at the data, it has not worked. Ultimately, when people need a fix, they're going to get their fix. The question is: Is sugar addictive? And the answer is weakly so, but absolutely and when you combine it with caffeine, strongly so. People are clearly addicted to soft drinks.
Will education alone in any form, whether it's packaging labelling with numbers of teaspoons, with grotesque images, actually work? Will any of these things work? Will any kind of public service announcements we do in schools or on TV have any beneficial effect in terms of consumption? Take a look at what happened in New York City. Mayor Bloomberg did many things. They did the man drinking fat. They did the number of packets of sugar in your soft drink. They even went to the USDA to try to get an exemption for food stamps to get soda off food stamps. Finally, there was the Bloomberg big gulp ban. The bottom line is that no one has changed their sugar consumption yet. Even with all of these educational efforts, no one has changed their sugar consumption yet, but could they? The answer is, all of those things contributed to education and education is absolutely paramount.
We've had an audience with two separate PR firms in Washington and in Houston for our non-profit, the Institute for Responsible Nutrition, to ask this question. What do we need to do, and what do we need to do first? They all said you can't do anything until you educate the public because the public has to be with you in order to see anything else through. So I'm totally for education, but if you think that education alone will solve this, think again.
This has to be followed up with some form of intervention, whether it is taxation, which is easy, restriction of access, which is harder, or if it is differential subsidization, which is the hardest but the best. Ultimately, something has to follow the education.
The Chair: Mr. Jeffery, do you have a comment on this?
Mr. Jeffery: Smoking rates have come down considerably in Canada over the past few years and anti-smoking advocates will tell you that it was because of the taxes, the labelling and the municipal bans in public spaces. These all contributed. They were another kind of consolation measure that you can take; I'm not a fan of putting the skull and crossbones on labels. I don't think that's right. If something is that dangerous it shouldn't be on the market at all.
There are areas where it makes sense to essentially ban foods, for instance, in schools. I think when children go to school they shouldn't be plied with junk food to raise money for school events. They should be provided with nutritious foods only. A lot of workplaces in this country have to think more about the food that's available in their cafeterias if they want to have productive workforces.
The one thing I would say is that our current regulations regarding what can appear on labels emphasized a lot on what kinds of market claims companies can make. The credo for our organization is that people should know the good news and the bad news, and there is too much good news on the fronts of labels and all the bad news is buried in details on the backs of labels.
The Chair: This has been a fascinating discussion. The discussion around the mouse-to-elephant labelling model has elicited the focused thoughtfulness as to what kind of labels might possibly have some indication. The reality that we're beginning to see, as several of the senators have mentioned, and both of you have clearly outlined, is that this is a complex area. This is not simple and it's certainly not simple for the average person to be able to comprehend.
I think you have illustrated and given very specific examples to the issues we are facing in terms of recommendations that we bring forward. I particularly appreciated that each of you outlined specific areas and recommendations, or areas in which recommendations could be focused, and you've both given us guidelines with regard to what those recommendations might look like.
The issue of labelling is not simple, but nevertheless we know that the public reacts to certain symbols fairly quickly. We've seen that with the packaging of pharmaceuticals in Europe and the U.S., with the black box and the black triangle concepts. There probably is something that will evolve out of this study that we can recommend. We may not be able to rent Senator Enverga's farm to get the source of symbols for this, but the idea is certainly one that is before us.
I think I can safely say on behalf of my colleagues on the committee that this has been a riveting meeting, that you have really brought the issues forward clearly, articulately, and in some cases with deserved energy. I want to thank you both for that.
Dr. Lustig, I appreciate the fact that you were patient with regard to getting hooked up by teleconference and from your great distance you have joined us today with enormously thoughtful input.
Mr. Jeffery, you have been very articulate through these issues and pointed out, in the Canadian context, aspects that we needed to be aware of.
(The committee adjourned.)