Interview Summary

Susan, I’ve respected your work for so many years. First, as a scientist – we were together on the faculty at Yale for a number of years. And now you work in government too. So it’s really nice to hear the word “perspectives.” So let me ask this as the first question. What do you think was the best thing that came out of the White House Conference?

From my perspective, it really drew a huge focus on the problem that we have been facing for a long time. The epidemic of diet-related chronic diseases, and how having good nutrition really can help reduce those diseases. As you know very well, this is something I’ve been working on for my entire career. What the White House Conference did is it really put a focus on that, provided inspiration and commitment to action, associated with this White House Conference. There were two very important deliverables that came along with that. The first one is a roadmap of actions that the federal government can take. In the “all of government” approach to end hunger and reduce diet-related diseases, while reducing disparities. The second deliverable is really a number of other commitments that others have made to really tackle this problem. I think we see this as a really great opportunity to accelerate the efforts that we have been trying to do, to get to a healthier food supply, and turn the tide on the epidemic of diet-related chronic disease that we have in this country.

Let’s talk about what the FDA can do in particular. There aren’t many people out there who probably know the full portfolio of FDA activities around food, because there are a number of them. So how do you think FDA can make a difference with this goal to end hunger, and to prevent diet-related diseases?

Yes, there are many ways the FDA can make a very big difference, and we have several deliverables in the White House strategy that really take advantage of two things that we do. One is through our labeling authorities, and we can discuss some of the labeling authorities and how those can really help turn the tide on diet-related chronic diseases. But we’re also working to have a healthier food supply for all, using tools outside of our labeling authorities. It’s really that combination of things that we can do, and how that can be leveraged by other federal agencies, so that we can be part of the solution. Obviously, FDA can’t solve this problem alone, this is a multifaceted problem. The problem of diet-related chronic disease, it requires multifaceted solutions. But FDA is proud to be part of the federal workforce that’s really trying to impact this problem of diet-related chronic disease.

When you mention “a healthy food supply,” in the context of FDA, some people would automatically think “That’s all about food safety, let’s make sure we don’t have foodborne illnesses.” That’s, of course, important, but you’re talking about a different thing: the long-term health consequences of food. FDA has a role there too, I’m suspecting?

Yes, we do. And our title, the name of the center that I lead, is the Center for Food Safety and Applied Nutrition. So nutrition has always been a foundation of what FDA does, and much of our work actually intersects the two together. And I’ll just give you one example is the work we are doing on food safety, for example, to get to better produce safety, so we have fewer outbreaks related to produce. That’s also critically important for our work on nutrition, because we want consumers to have confidence in fresh produce, consume more of it, to be more consistent with what the dietary guidelines recommends, and that instead will improve nutrition. So food safety and nutrition are both interrelated in the work that we do at FDA.

If the goal is for people to be able to eat healthier foods, part of that is people knowing how healthy foods are. So how do you work on that issue?

Well, a couple things to emphasize, one is that education is critically important. And, when it comes to education around health and nutrition, we partner with the US Department of Agriculture, the Centers for Disease Control and Prevention, in a lot of these educational efforts to educate consumers, to make sure that they know what healthy eating should look like. But interestingly, another piece of this is that if you ask consumers where they go to, and who they trust for nutrition information, they will frequently tell you that their most trusted source is their doctors. It’s also important, not just that the federal agencies are working on this, but medical professionals also really need to be educated about nutrition, so that they can help their patients. We have produced some continuing education models for physicians on food labeling, and how they can use that to counsel their patients. I would like to see more nutrition incorporated into the medical exams and board certifications. So we incentivize more nutrition training for physicians, and some of these concepts are built into the national strategy on nutrition, released around the White House Conference.

You’ve mentioned food labeling several times, and when people think about food labels, they naturally think of the ingredient label, and they think of the nutrition facts panel that’s on the side, or the back of packages. But there’s been talk over the years about the possibility of some sort of a labeling system on the front of the package, which would be a quick guide for consumers to understand how healthy a food might be overall. I’m just not aware of where discussions stand in FDA about that now, and I’m hoping you might bring us up to date.

Happy to. You know, we look at food labeling holistically. There are different claims that we regulate on food labels, things like a healthy claim that currently exists that we’ve been working to update. Those are claims that we regulate. You asked specifically about front-of-pack labeling. As part of the national strategy on nutrition, we did make a commitment to work on developing a front-of-pack labeling scheme that could help consumers make those types of decisions quickly, through front-of-pack labeling. So there are many labeling tools that we have, whether it be claims around healthy, dietary guidance statements, front-of-pack labeling. In addition to the nutrition facts labels and ingredient statements. Those are all pieces that can really help inform consumers about the foods that they are purchasing.

You have to look around the world at these front-of-pack package labeling systems, there are lots of different types. I mean, some are like a stoplight program, with red, yellow, and green symbols to indicate how much overall nutrition, or unhealthy things that food might have. Others talk about specific ingredients. Is there a consensus around the field now about which of those systems might be most effective and helpful to consumers?

So, one of the things we’ve been doing is really looking at that international landscape. We have learned a lot about what different countries are doing, and what those countries have learned about the various systems. As part of our commitment to develop a front-of-pack label system in the United States, we are learning from the vast international experience that is out there. We are in early phases of this, but I can assure you that FDA’s work will be informed by what’s happening in the international landscape. At the same time, we are interested in how our own consumers respond to different front-of-pack labeling systems. We have begun, and completed, a first-round of consumer studies. We have a consumer studies branch in my center where we test how consumers interact with various labeling systems. So we’ve completed some qualitative research, some focus groups, and we’re looking forward to additional consumer research that would help guide us being informed by our own work, as well as what’s happened in other countries, in terms of a potential path forward for the US.

I’m really happy to hear that, because that kind of work in the United States needed to be done in the kind of big way, you’re probably able to do it. So I’m really happy to hear that news. So if you come upon a system that you feel might work best in our own country, what’s the process for actually having something like that on packages? I mean, does Congress need to approve? Is that something the FDA can do on its own? What sort of route might it take?

I can’t foreshadow specifically which route we would take, but FDA will issue guidance, or regulations, in terms of where we would be going. Under any scenario, it’s important to us that we get public comment on anything that we would be doing. So for example, we could issue a proposed rule on a particular labeling pathway, that would then go through a public comment process before we would make anything final. A key part of all of this work is extensive stakeholder engagement, and that means hearing from a number of different stakeholders; our consumer groups, the academic sector, the industry, to provide information into our process. There would be multiple places where we get input for any system that we would be moving forward. It obviously would involve extensive public comment before we would finalize the next steps.

It’ll be really interesting to see what happens with that. And ultimately, what we might find on the front of packages in the United States. Let’s return to the national strategy. The national strategy discusses all of the government response. You mentioned before connecting, with CDC, USDA, other parts of government. Are there some examples you could give us about how different government agencies can work together to make progress? How that might work, and what kind of issues might be involved?

Sure, with regard to some of our own work, for example, we’re not only using our labeling authorities, but we’ve also taken other steps to have a healthier food supply. I’ll give you one example, and that’s our work to reduce sodium in packaged foods. We have issued targets for industry to level the playing field, and gradually reduce the amount of sodium in the food supply. Our sodium targets hit not only packaged foods, but also restaurant and retail as well. What we’ve done in the national strategy is we’ve talked about how other government partners can leverage FDA’s sodium work. For example, the VA, the Veteran’s Administration, they are planning to increase procurement of lower sodium foods consistent with FDA’s targets. We’re also partnering with HHS administration for community livings administration on aging, to help older adult nutrition programs. That they would provide lower sodium options consistent with FDA’s targets. USDA has been using FDA’s targets as they’re working to reduce sodium in school meals. This is an example where FDA can take an action, and it can be leveraged and amplified, including through the power of procurement through the federal government, to get to a healthier food supply for all.

I’m really happy you mentioned “procurement,” because you’re right, that can be very powerful, and the government has so much sway in that respect. This is the final question, let me just follow up on this sodium issue, because I think it’s really an interesting one. Consumers might hear the term “lower sodium,” and think that means lower taste. I think the strategy that some people have discussed is that the diet became high in sodium without people really knowing so much that it was happening. People just got accustomed to a very high level of sodium in their day-to-day foods. But that if it gradually got reduced, it would happen in a way that consumers wouldn’t even notice each little decline, because it would be gradual. But they’d become re-calibrated to a new standard that they would find just as pleasant, it would just be lower in sodium. Is that kind of the way the thinking goes?

That is a key part of our sodium strategy. What we heard from the food industry is that if they tried to reduce sodium in foods to promote better nutrition that consumers might recognize that those products tasted different from other foods that had not been reduced in sodium. That in order for us to make progress, we needed to level the playing field, so all of the industry was reducing sodium incrementally at the same time. The reason this can work is because sodium is an adaptive taste, and so we can all adapt to these lower sodium foods. Consumers wouldn’t even notice these minor adjustments as you begin to ratchet down the amount of sodium in the food supply. These changes can help, gradually, across a population, have really important health benefits.