September 2017 Issue

Food Fears
By Mindy Hermann, MBA, RDN; Michael P. Holsapple, PhD, ATS; and Heather E. Dover, RDN
Today's Dietitian
Vol. 19, No. 9, P. 32

Are packaging claims such as "free from," "clean," "natural," and "organic" deterrents to healthful eating?

Clean. Free-from. Natural. Organic. Non-GMO. These marketing buzzwords featured on product packaging communicate to consumers that the products are healthful and better for the environment. Today's shoppers often rely on these claims more than nutrient content.

However, buzzwords can backfire when they foster fear and scare consumers away from healthful, accessible, and affordable food choices. For example, the fear of ingesting pesticides often prevents people from eating produce if they can't afford organic varieties. Fear of GMOs may steer them away from healthful foods that aren't marked non-GMO. Unfamiliar names for vitamins in fortified cereal can lead to choosing a less nutritious, unfortified brand.

"The food and nutrition environment has changed in recent years from proactive to reactive," says Leah McGrath, RD, LDN, a retail dietitian at Ingles Markets in Asheville, North Carolina. "Questions I receive during talks, via e-mail, or on social media are almost all fear-based, and the level of food fears is overwhelming."

Factors Fostering Food Fears
The health halo surrounding organics has led to fear of conventional foods. In one study, in-depth interviews revealed that some study participants attributed health issues such as cancer, weight gain, and allergies to eating foods that weren't organic.1 Fruit and vegetable consumption—consistently below recommended levels—is particularly vulnerable to the effects of fear. Huang and colleagues surveyed low-income shoppers to learn about their attitudes concerning organic and conventional fruits and vegetables. Those who had heard messages about pesticide residues on produce were less likely to purchase any type of fruits and vegetables, conventional or organic.2

However, according to the Organic Trade Association Organic Market Analysis, more than 82% of US households buy organic foods, and organic food sales have nearly doubled over the past 10 years.3 Although "organic" is a production term that doesn't address quality, safety, or nutrition, the public thinks otherwise. A 2016 Pew Research Center study found that a majority of people say organic produce is more healthful than conventional.4 Research, however, supports a different conclusion: Conventionally grown produce doesn't differ nutritionally from organic crops. Furthermore, farmers of both organic and conventionally grown crops typically rely on pesticide use. Organic farmers can use products with approved natural and synthetic substances, and conventional farmers can do the same, with a couple of important caveats.

First, due to their low toxicity, many natural pesticides are exempt from US Environmental Protection Agency (EPA) requirements for a tolerance limit for residues on food. Second, in contrast with conventional pesticides, data on pesticide use in organic farming are limited. Organic and conventional produce each offer benefits, and consumers who choose not to purchase organic produce because of cost, availability, or other factors need not fear that conventional produce is unsafe.

Fear-based messaging also can pressure the food industry to steer clear of food additives that have beneficial uses. Bedale and colleagues assert that today's antiadditive sentiment leads to consumer fears of preservatives such as nitrate and nitrite in meat, even though changes in processing methods have reduced health risks and the benefits of nitrate consumption are better understood.5

Hazard or Risk?
Misperceptions of risk as it relates to the presence of a hazard, and a general lack of understanding of the benefit-risk relationship, both contribute to food fears. The EPA has developed a four-step human health risk assessment model to estimate the nature and probability of adverse health effects in humans who may be exposed to chemicals in the environment6:

Step 1. Hazard Identification: Can a substance cause harm to humans and under what conditions?

Step 2. Dose Response Assessment: What's the relationship between exposure and effect?

Step 3. Exposure Assessment: What's the frequency, timing, and level of contact with the hazard?

Step 4. Risk Characterization: What's the risk to health based on the hazard and exposure?

Here, it's important to understand the difference between hazard, which is something that could cause harm, and risk, which represents the probability that harm will occur at a given exposure. A shark can be used as a metaphor for the difference between a hazard and a risk. Sharks have sharp teeth and powerful jaws that certainly could cause harm; the shark is therefore unquestionably a hazard. However, viewing the hazardous shark at an aquarium poses a much diminished risk compared with swimming in shark-infested waters, because of a lower probability for exposure.

The health community uses both hazard- and risk-based approaches to food safety, and each offers advantages and disadvantages.7 A hazard-based approach is easier to regulate and explain because all potentially harmful compounds are included. However, it can lead to overuse of precautionary statements such as "may contain," and therefore may be impractical.

A risk-based approach quantifies and prioritizes risk while considering potential benefits. However, it requires more time and data to evaluate each hazard. Various terms describe the dose-response approach to risk assessment that establishes the highest doses at which no toxic effects are identified (No Observed Adverse Effect Level) and the lowest doses at which toxic effects are observed (Lowest Observed Adverse Effect Level).

Evaluation of the herbicide glyphosate provides an example of the different conclusions drawn by hazard-based and risk-based approaches. Using a hazard-based approach of cancer causation under any possible situation, the World Health Organization (WHO) International Agency for Research on Cancer states that glyphosate is "probably carcinogenic to humans." The Food and Agriculture Organization (FAO)/WHO Joint Meeting on Pesticide Residues considered whether the chemical causes cancer in real-life situations and concluded that "glyphosate is unlikely to pose a carcinogenic risk to humans from exposure through the diet." It can be argued that the conclusion from a risk-based approach, with its focus on the importance of exposure is, by design, much more relevant to our lives.

The highly publicized pesticide scoring system of the Environmental Working Group (EWG), which each year names the "Dirty Dozen" fruits and vegetables, errs by conflating hazard with risk. It considers that all pesticides are equally toxic and that any exposure to a pesticide is toxic. Effectively, the EWG equates the presence of any pesticide residue as a risk, rather than relating detected pesticide residues to known safety standards. The EWG publicizes these results annually even though the actual levels are almost always below established tolerances, that is, their presence represents a hazard but not a risk.

Interestingly, in addition to publishing their annual "Dirty Dozen" list, the EWG also presents a series of frequently asked questions on its website. In its response to the question, "Should we eat more fruits and vegetables?" the EWG says, "The health benefits of a diet rich in fruits and vegetables outweigh the risks of pesticide exposure. Eating conventionally grown products is far better than skipping fruits and vegetables." Unfortunately, there's no direct link from the "Dirty Dozen" warnings to this more balanced and appropriate response from a diet and health perspective.

The USDA's Pesticide Data Program (PDP) produces the most comprehensive annual pesticide residue database in the United States. Data from the PDP enable the EPA to assess dietary exposure, particularly among commodities highly consumed by infants and children, and provide guidance for the FDA and other governmental agencies to make informed decisions. Importantly, over the 20 years that the PDP has been testing residues, ~99% of the crops and commodities have tested below and, most often, significantly below tolerance levels set by the EPA. The USDA has consistently emphasized that "based on the PDP data, consumers can feel confident about eating a diet that is rich in fresh fruits and vegetables." Notably, the EWG develops its annual "Dirty Dozen" list based on the results of the analyses conducted by the PDP the previous year.

Fundamentals for Communicating Risk
Dietitians can do their part to avoid escalating food fears by learning and educating clients about risk. The FAO/WHO Risk Communication Applied to Food Safety handbook lists openness, transparency, timeliness, and responsiveness as key principles of good risk communication.8 The handbook also notes the importance of building trust (people rely on personal trust when deciding between conflicting messages) through providing or citing credible and independent scientific information and being honest.

To put food safety risk communication into action, FAO/WHO recommends comprehending the nature of risks, benefits, and hazards; assessing available data; understanding what can be done; and dealing with unintended consequences. Dietitians also should consider cultural and socioeconomic background, history of the risk, and any related political and media issues when working to understand client perspectives.

Researchers at Cornell University examined how experts could correct misperceptions among individuals who were most likely to have food fears. They found that providing participants with historical and contextual information about an ingredient led to higher ratings of healthfulness. The authors noted that information regarding an ingredient's history, functions, uses, and benefits may help alleviate fears.9

Helping Clients Overcome Food Fears
As RDs fight fears with facts and speculation with science, face-to-face conversations may be more effective than social media. According to the International Food Information Council Foundation 2017 Food & Health Survey,10 a higher percentage of respondents said they trust advice from a conversation with an RD compared with an RD's advice on social media or on a health, food, or nutrition blog. "I use multiple outlets, including talks, in-store radio, podcasts, articles I write for magazines, social media, and the Ingles website (www.inglesinfoaisle.com) to help shoppers sort out good information from bad," McGrath says.

Empathy is the most important starting point when working with clients who have fears of foods or ingredients. Whether counseling patients, working with supermarket shoppers, communicating through social media, or interacting in other ways, dietitians first should try to understand where clients are coming from. "They may be afraid of developing cancer or putting something toxic into their body, or just trying to do the best job possible raising a healthy child," says Melinda Johnson, MS, RDN, a clinical associate professor in the school of nutrition and health promotion at Arizona State University. "Once you see fear through their eyes, you will be better equipped to guide them toward credible information that is relevant to them."

"I help clients take apart their beliefs and fears, many of which turn out to be irrational," says Karin Kratina, PhD, RD, LDN, a nutrition therapist, author, and speaker in Gainesville, Florida. "Food choices that are mediated by fear are stressful and unhealthy, and people really want to be healthy. I share reliable articles with my clients during appointments and on my website."

Evelyn Tribole, MS, RDN, coauthor of Intuitive Eating: A Revolutionary Program that Works and owner of a nutrition counseling practice in Newport Beach, California, works with a growing number of clients who have orthorexia, an eating disorder characterized by an extreme focus on healthful eating. She notes that many clients become so rigid and fearful of foods perceived as unhealthful that they won't eat at other people's homes. "Social media is a main culprit because it fosters all-or-none attitudes, food guilt trips, and fear mongering," Tribole says. "I discuss with my clients whether social media is helping or harming their recovery."

When necessary, Kratina will put clients on a social media "diet" that calls for ignoring or deleting any messages about food and fear of food. She finds that periodically turning away from less credible sources and reading only science-based information strengthens her own ability not to be influenced by fear.

Johnson often relies on health professionals and organizations that offer resources on chemical literacy. "Observing or reading about how they explain the complicated topic of biotechnology and handle emotionally charged conversations adds to my own communication toolbox," Johnson says. She also seeks out farmers through social media sites for answers to questions about farming practices.

"People shut off when they get overwhelmed by too much information, so keep messaging simple," says Chris Vogliano, MS, RDN, who consults on wellness, sustainability, and the environment in Seattle. "Eat a diverse diet with more whole and plant-based foods. Live a healthful lifestyle. Don't smoke. Use sunscreen. Don't sit all day. And don't obsess over avoiding toxins because it's impossible."

Joan Salge Blake, EdD, RDN, LDN, FAND, a clinical associate professor at Boston University, says that because a diet rich in fruits and vegetables is associated with numerous health benefits and few risks, "we have to continue educating people that all fruits and vegetables are good for you. The best path to health through produce is to buy what's on sale—those items are more likely to be in season, local, abundant, affordable, and tasty."

— Mindy Hermann, MBA, RDN, is president of Hermann Communications in Somers, New York, and a contributing writer for Produce Business and Organic Produce Network.

— Michael P. Holsapple, PhD, ATS, is director and endowed chair at the Center for Research on Ingredient Safety (CRIS), and a professor of food science and human nutrition at Michigan State University in East Lansing, Michigan. CRIS is a partnership between academia, industry, government, and nongovernmental organizations focused on chemical-based ingredient safety. CRIS conducts research and provides insight on the safety of ingredients in food and consumer products to support evidence-informed decisions by consumers, industry, and policy makers.

— Heather E. Dover, RDN, is a research assistant at CRIS at Michigan State University.

References
1. Rodman SO, Palmer AM, Zachary DA, Hopkins LC, Surkan PJ. "They just say organic food is healthier": perceptions of healthy food among supermarket shoppers in southwest Baltimore. Cult Agric Food Environ. 2014;36(2):83-92.

2. Huang Y, Edirisinghe I, Burton-Freeman BM. Low-income shoppers and fruit and vegetables. What do they think? Nutr Today. 2016;51(5):242-250.

3. Organic market analysis. Organic Trade Association website. https://www.ota.com/resources/market-analysis. Accessed June 12, 2017.

4. Funk C, Kennedy B. The new food fights: U.S. public divides over food science. Pew Research Center website. http://www.pewinternet.org/2016/12/01/the-new-food-fights/. Published December 1, 2016. Accessed February 10, 2017.

5. Bedale W, Sindelar JJ, Milkowski AL. Dietary nitrate and nitrite: benefits, risks, and evolving perceptions. Meat Sci. 2016;120:85-92.

6. Conducting a human health risk assessment. Environmental Protection Agency website. http://www.epa.gov/risk/conducting-human-health-risk-assessment. Accessed April 22, 2017.

7. Barlow SM, Boobis AR, Bridges J, et al. The role of hazard- and risk-based approaches in ensuring food safety. Trends Food Sci Technol. 2015;46(2, Part A):176-188.

8. Food and Agriculture Organization/World Health Organization. Risk communication applied to food safety: handbook. (Food safety and quality series, 2). http://www.who.int/foodsafety/Risk-Communication/en/. Published 2016. Accessed June 14, 2017.

9. Wansink B, Tal A, Brumberg A. Ingredient-based food fears and avoidance: antecedents and antidotes. Food Qual Prefer. 2014;38:40-48.

10. 2017 food and health survey: "a healthy perspective: understanding American food values." International Food Information Council Foundation website. http://www.foodinsight.org/2017-food-and-health-survey. Updated July 17, 2017. Accessed May 17, 2017.