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They seem at first a saving gracefor parents of picky eaters: asource of calcium, made with

whole wheat, low in saturated andtrans fats; iGor muffins look and tastelike chocolate Twinkies. On the frontof the package, a cartoon gorilla grinsat children wandering the groceryaisles with their parents. The box’supper right-hand corner displays theHeart and Stroke Foundation ofCanada’s “Health Check” logo.

The nutrition information on theback of the package reveals — in muchsmaller print — that the muffins are al-most one-third sugar.

iGor muffins are one of severalHealth-Checked products a Canadianobesity expert is up in arms about. TheHeart and Stroke Foundation of Canadawants Health Check to become part of amandatory national food labeling policy,but Dr. Yoni Freedhoff, the medical di-rector of the Ottawa-based BariatricMedical Institute, says putting the seal ofapproval on foods that are high in sugaror sodium, or that contain red meat orrefined flours, is a betrayal of the trustCanadians place in the Foundation.

“As much as muffins and cookies area delicious part of our lives, to try and tellpeople that they’re a healthy choice inour diet is just madness,” Freedhoff says.

national Sodium Policy Statement re-leased by Blood Pressure Canada, whichsays that about 1 million Canadians havehypertension as a result of salt con-sumption levels. The statement recom-mended consuming between 1200 and2300 mg of sodium per day; the averageCanadian consumes about 3500 mg.

It would be easy to eat a whole days’worth of sodium in 1 meal at BostonPizza, eating only Health Checkedmenu items. The lime and parmesanshrimp skewers appetizer, for example,has 1110 mg of sodium. The Thaichicken wrap has 1180 mg.

But Samis says the sodium contentin Health Checked products is gener-ally lower than in comparable items,and the Foundation is gradually reduc-ing the allowable amount of sodium.“The sodium policy statement talkedabout getting Canadians down to 1500mg per day by 2020, not by tomorrow,and that’s very important. … It takestime to adjust the consumer palatedownward. Canadians eat a lot ofsodium. They’re used to eating a lot ofsodium. They expect their food to havea certain taste and texture, and sodiumis part of that.”

He particularly objects to HealthChecked items in the Compliments Ju-nior Disney-line of foods, which includesitems like Mickey Mouse-shaped beefburgers, letter-shaped tater tots, andsweetened, flavoured “Milk Buddies.”

“There is more sugar and more calo-ries than Coca-Cola in these beveragesthat they’re marketing with Disneycharacters to children as healthychoices,” Freedhoff says. “Parents willthink, ‘This is great, I’m going to givethese to my kids.’ Basically, they’re justshoveling sugar into their mouths.”

The Heart and Stroke Foundation ofCanada charges licensing fees for inclu-sion in Health Check, which requiresthat products meet nutrient criteriabased on Canada’s Food Guide toHealthy Eating. Terry Dean, the generalmanager of Health Check, says the feesallow the program to be self-supporting(Box 1). As of last fall, there were 1225products bearing the Health Check logo.

Dean says the program is loweringthe amounts of acceptable added sugarto match 2007 revisions to the foodguide. iGor muffins are one of manyproducts that will have to change in or-der to meet the new criteria. “We’re giv-ing people time to reformulate, becausewe don’t want them defaulting to higherlevels and going out of the program, soour hope is that they can do it.”

But it’s not just sugar and caloriesthat make the program questionable,Freedhoff says. The World Cancer Re-search Fund released a report in earlyNovember linking the consumption ofred and processed meats with cancer,but Health Checks still appear on lunchmeats and lean beef.

Stephen Samis, the Heart andStroke Foundation of Canada’s directorof health policy, takes issue with Freed-hoff’s interpretation of the cancer re-port, which “did not say, ‘don’t eat redmeat. It said, ‘limit your consumptionof red meat,’ and it said ‘limit your con-sumption to something like 4-5 serv-ings per week.’”

Millions of Canadians eat red meat,he says. “So what we’ve done is said,look, if you’re going to eat red meat,this is the kind of red meat that we rec-ommend you eat — red meat that islean or extra lean.”

Last fall, the Foundation endorsed a

Checking up on Health Check

CMAJ • February 12, 2008 • 178(4) OOnnlliinnee--11

Early release, published at www.cmaj.ca onJan. 17, 2008. Print version subject to revision.

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Dr. Yoni Freedhoff, Ottawa-based spe-cialist in obesity medicine, seen herejogging on the office treadmill, believesthat parents are often “shovelling sugar”into the mouths of their children whenthey indulge them with some foods bear-ing The Heart and Stroke Foundation’s“Health Check” imprimatur.

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Early release, published at www.cmaj.ca on January 17, 2008. Subject to revision.

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That’s not good enough, Freedhoffcounters. “You just can’t have it bothways. You can’t say that we should re-duce sodium and then recommendproducts high in sodium.”

Freedhoff says part of the problem isthat Health Check is based on the foodguide, which he believes is heavily influ-enced by the beef, dairy and restaurantindustries (CMAJ 2005;174[5]:605-6and CMAJ 2006;175[6]:752-3). “I’m notsure it would look good for the number3 beef-producing country in the worldto say, ‘beef’s not good for you.’Canada’s got a $20 billion dairy indus-try. It’s going to be a difficult thing tosay we should be drinking less milk.”

The Heart and Stroke Foundation’s

ing to argue whether that number ishigh or low. … I think Heart and Strokeis doing the best they can, in terms ofprobably being the strictest out there.”

Cronier also acknowledges thathealthy choices are invariably easier fora dietitian than for the average con-sumer. “Some consumers are reallylooking for that little logo or check orwhatever to reinforce their choice sothey don’t have to think about it.”

Samira Barakat, a mother of 2 whoworks at Winners, notices the HealthCheck on certain foods, but also paysattention to nutrition information onthe back of packages. “I always check. Idon’t go by the picture,” she says.

Retired teacher Norma Dowdles issimilarly skeptical. “Having seen thislabel [points at Health Check logo] andthis label together [points at “V” forVachon brand name on iGor muffins),”Dowdles says “I would probably makemy own judgment, to be honest.”

For them, the issue is not clear-cut. For Freedhoff, it is. “This is so —

for me anyhow — black and whitewrong.” But he emphasizes that hisproblem is with Health Check, not theFoundation. “I think it’s a great organi-zation. So, I want to be very clear: I’mnot bashing them, but I am bashingHealth Check because it’s just not whatwe understand to be true about diet andnutrition, and it promotes the very dis-eases that the Heart and Stroke Foun-dation is supposed to be rallyingagainst.”

Samis respects Freedhoff’s passionand concern for Canadians’ health, butadds that “he’s not the sole arbiter ofhealthy eating in the country. He hatesCanada’s Food Guide. We respect that.We don’t necessarily agree with him,but the food guide was established byhundreds of experts.”

“It’s important that there are peoplein the country who are encouragingpeople to eat as healthfully as possible.We feel that that’s exactly what we doas part of the Heart and Stroke Founda-tion as well, and feel really that we’reactually trying to achieve the samekinds of things,” Samis adds. “At theend of the day, the ends are the same.”— Amanda Truscott, Ottawa, Ont.

DOI:10.1503/cmaj.080030

adherence to the food guide could bepolitically motivated, linked to its at-tempts to get Health Check included ina national front-of-package labelingprogram, Freedhoff surmises. “I don’tthink that we could have a national pro-gram sponsored by our governmentthat was at odds with our food guide.”

But not all nutrition experts agreewith Freedhoff’s condemnation of foodguide’s recommendations as “nutri-tionally indefensible.”

Registered Dietitian Claire Cronierhas mixed feelings about Health Check.“I believe that one has to look at a totaldiet rather than singling out individualfoods. Everybody’s going to have a stan-dard or a number, and we’re always go-

CMAJ • February 12, 2008 • 178(4) OOnnlliinnee--22

Box 1: Health Check

The program was created in 1999 by the Heart and Stroke Foundation of Canada as a quick means of identifying foods and restaurant menu items that meet nutrient criteria based on Canada’s Food Guide. “It’s like shopping with the Heart and Stroke Foundation’s dietitians,” organizers say.

Procedures:

Food manufacturers or restaurants submit applications for Health Check approval for a specific product or menu item. Applications must include a nutrient analysis.

Applications are reviewed by Foundation dietitians and evaluated against specific Health Check serving sizes. Those who meet the test are issued a license to use the Health Check symbol on their labels or menus. Criteria:

Criteria are established by a Health Check Technical Advisory Committee “made up of dietitians and nutritional experts from across the country.”

Nutrient criteria (available at: healthcheck.org) are fairly extensive. They were slightly revised in mid-January, with the changes to take effect in December, 2009 for existing products, and immediately for new ones. Generally, a product must meet “entry-level” maximums for total fat, saturated fat, protein and sodium content.

For example, a 55 g serving of a breakfast cereal must have low or no added fat (3 g or less), have at least 2 g of fibre and a sodium level under 480 mg. Under recent revisions, the cereal will also have to meet the tests of having less than 11 g of sugars “excluding sugars from pieces of fruits except if 6 g or more fibre,” while having a trans fat ratio of less than 5% of its total fat content. Fees:

Applicants pay a 1-time evaluation fee and an annual licensing fee, both of which are pegged to a sliding scale based on the nature of the product and “the size of the market.”

The evaluation fee ranges from $150-$750. The annual licensing fee ranges from $1225 to $3625. Discounts are available to companies offering multiple products. A company with 14 or more products pays a maximum annual fee of $16 500 to $49 500, depending upon the food category. Companies that reach the maximum 14 in 4 different categories pay a maximum $66 000 to $180 000, again depending on the specific food categories that their products fall under. Health Check spokesperson Danielle Côté says that translates into gross revenues of $2.6 million per year.

Source: The Heart and Stroke Foundation of Canada