My (Paid) Friend Says This Product Is Really Good: FFTB and Cherry-Picking

Visiting Professor Patrick Holford of Teesside University and the Food for the Brain Foundation (FFTB) are promoting a very well-thought plan whereby food and supplement manufacturers will give them money in exchange for the endorsement of their products. Now, charities have to get their money from somewhere, so isn’t that all very sensible?

It’s unfortunate that while some of the initial crop of endorsements are unexceptional, others have a little hint of controversy: e.g., Equazen and Cherry Active. Readers may recall that Equazen eye Q was recently reprimanded by the ASA for over-stating the demonstrable benefits of its products. We don’t know what evidence Cherry Active submitted to FFTB as part of their accreditation but the nutritional information on their website is misleading- not that FFTB has any competence with number-handling – and they over-state the health benefits for their products and fail to provide appropriate references – the latter is something that FFTB has done itself. Even on the basis of its own criteria, the Cherry Active dried cherries fail 3/4 of the critieria and the evidence for the 5th is equivocal so the FFTB endorsement must be attributable to cherry-picking (you knew it was coming). So, birds of a feather, plus ca change and is there a problem?

We’ve just seen the outcome of a case where Alzheimer’s Society joined forces with Eisai and Pfizer to compel disclosure of the NICE economic model for ajudicating prescription decisions. It will be interesting to see the eventual outcome of that.

Anthony Cox has a thoughtful piece on Abatacept and patient groups. He highlights a noticeable trend towards patient support groups being financed by manfacturers as a way of influencing campaigns such as the Informed Patient Initiative. Cox usefully quotes Herxheimer:

Most patients’ organisations are poor and have little independent funding. Grants from and joint projects with pharmaceutical companies can help them grow and be more influential, but can also distort and misrepresent their agendas. Relationships must therefore be fully acknowledged and open, without public relations flummery.

There are charities that are partners in some very fine research programmes. They combine such work with vigorous advocacy for patients and their families. However, Holfordwatch wonders if there is an insidious shift in progress towards using charities to provide endorsements for commercial products and to give them cover for making claims that they might otherwise be restricted from making.

Sometimes, when there isn’t a clear financial relationship, it looks like the charities are issuing as lukewarm an endorsement as they can get away with, or it is being uttered through gritted teeth because the charity is being pragmatic and they know that they have to say something because the product is in their bailiwick. E.g., Biocard reproduce what looks like an endorsement from Coeliac UK but the full statement, to which they link, is far more nuanced and cautious.

Other charities have no such inhibitions and openly celebrate their relationship with manufacturers. An obvious example is Heart Research UK and Pomegreat; they openly solicit other sponsorship opportunities.

Last year, the House of Lords recommended that Allergy UK should not endorse direct-to-consumer tests for allergies or food intolerance because there is an “absence of stringent scientific evidence” to support the tests. In January we noticed that AUK has created another division that is dedicated to food intolerance awareness. Part of YorkTest’s credibility with the public is the often-repeated fact that it is recognised by AUK, although this is only a Consumer Award and based on anecdote rather than clinical evidence, and YorkTest pays an annual fee for it to be renewed.

FIA gives some decent advice about the elimination and challenge method for identifying food intolerances. They even discuss allergy tests that have no scientific support such as Vega and Applied Kinesiology. However, they don’t mention the House of Lords’ criticism of YorkTest’s tests nor the plea that responsible professionals should not recommend those tests and that charities should not endorse them. And, it’s unsettling that the FIA recommends that people should consult a (preferably BANT registered) nutritionist but neglect to mention Registered Dietitians. Particularly given that so many members of BANT are graduates of the Institute of Optimum Nutrition and IgG testing for food intolerance is a common thread in their practices; and, it is unlikely that Registered Dietitians are quite as supportive of non-conventional or evidence-light tests.

There is something remarkably déjà entendu et déjà compris about the site and, in a striking coincidence, it looks like Les Rowley of YorkTest set up a Food Intolerance Awareness Group last year. Now, although YorkTest is not explicitly mentioned on the FIA site as yet, it feels pervasive. You might feel that AUK trawled far and wide for many perspectives on food intolerance and it is no more than another unremarkable coincidence that all of the FIA panel of experts have YorkTest connections in one way or another and, specifically, to the test that was deprecated in the House of Lords’ report.^[1]

If you are familiar with the YorkTest range of products, it is hard not to see the correspondences in the FIA page on Allergy or Intolerance? The section about the enzymes? In addition, YorkTest has recently announced a Gut Health Test. When you look up more information, it seems that the test will tell you about your candida status^[2] and let you know if you lack necessary digestive enzymes or are failing to produce sufficient hydrochloric acid. You may need to consult a nutritionist about this; and given the nature of the test, it is likely that a nutritional therapist rather than a Registered Dietitian will be familiar with such tests although it is Registered Dietitians such as Rhona Hobday who have recently assessed anti-Candida diets and found them to be unhelpful.^[3]

AUK benefits financially from endorsing YorkTest and YorkTest has a marketing advantage in being able to promote some of their products as ‘endorsed by Allergy UK’; a fact that is mentioned prominently on their website and in their frequent press releases. It is a sensible, mutually beneficial arrangement. However, there is a niggling sense that this is not quite within the spirit of the House of Lords’ recommendation. There is also a slight qualm that there is a potential for the public to believe (rightly or wrongly) that the fact something is endorsed by a charity means that any health benefits are medically-approved and evidence-based even when a particular product has been the subject of explicit criticism.

Which brings us to the latest, unbelievably well-thought-out marketing plan where FFTB is selling its endorsement of various products and supplements. We’ve mentioned Equazen and their recent brush with the ASA. FFTB has also endorsed the Cherry Active range.^[4] Cherry Active makes some vigorous and outlandish health claims for the benefits of its products;^[5] claims that they might not be able to make on their own behalf in the future, depending on the impact of the Office of Fair Trading Unfair Commercial Practices Directive (pdf) and the Nutrition and Health Claims regulations.^[6]

So, what is being said about these cherries? Cherry Active proudly states:

Food for the brain – leading nutritionist Patrick Holford recommends CherryActive Cherries as a snack for children to help boost concentration and energy levels

Well, yes, it is amazing what people will recommend when you pay them to endorse you. There is no distinctive evidence to support the cherry snack rather than an apple or orange or similar, but hey ho. Irritatingly, the nutritional information on Cherry Active’s website is misleading. The claim that, “[t]hey also contain virtually no carbohydrate” looks like it is related to both the cherry concentrate drink and the capsules but it only relates to the capsules. It also fails to point out the one of the reasons that a capsule contains little carbohydrate (they refer to less than 0.5g) is because it contains 500mg of powder. Which is practically the entire weight, if the quoted details are correct.

The nutritional table reports that for the dried cherries 41/50g are carbohydrates which makes sense: there are 170 kcalories in 50g and the carbohydrates contribute around 160 of them (we’ve subtracted for the dietary fibre). However, there are some carbohydrates unaccounted for as the sugar grammes, as stated, are 15.3g fructose and 18.3g glucose or around 34g.

However, if we go by the information as given, then the glycaemic load of these cherries (one of the criteria for endorsement) is unimpressive. If you look at Patrick Holford’s guide to glycemic load (GL), you will notice that the usual serving size for a dried fruit like raisins is 60g. The manufacturer sells 65g bags of dried cherries, so you might think that is a useful snack size. No, it seems that the recommended portion size is half a bag or 32.5g although not for any clearly-stated reason. If you calculate the GL^[6] for 65g of dried cherries, using the website information, then you would calculate (58 (estimated glycemic index from website) x 52 (number of carbohydrate grammes in a serving, we’ve subtracted the fibre)) and divide that by 100. Your result would be a GL of 30 which is “bad” according to Patrick Holford. 32.5g of dried cherries is 15 which is still “bad” but might be nudged into being OK-ish.^{[8, 9]}

Now, the stated criteria for an FFTB audit and endorsement are:

• Low GL
• High in essential fats (omega 3,6 and phospholipids)
• High in vitamins and minerals
• Free from harmful or unnecessary chemical additives or colourings
• Low in sugar

You might be able to finagle the calculation of the GL of the dried cherries a little but it is not possible to make them a low GL food even for as little as 32.5g. At 68g+ per 100g in named sugars, they are certainly not ‘low in sugar’ as a percentage of their overall calories; again, you can only artificially depress the absolute amount of sugar by stipulating a small serving size (the FSA states that anything with more than 15g of sugar per 100g is high which is a crude method but indicative here).

The dried cherries are neither “low GL” nor “low in sugar”. Self-evidently, they are not high in essential fats. The website doesn’t provide the full vitamin and mineral profile so we can’t make a judgment as to that claim but we consider the claim equivocal. We have tracked down some sort of profile for what looks like a similar cherry product (pdf) and the values don’t indicate that dried cherries are ‘high in vitamins and minerals’. E.g., per 100g there is O.5mg of Vitamin C so it is safe to say that there is a negligible amount in the recommended serving size of 32.5g. At 3580mg of Vitamin A, that might be a reasonable source but not strikingly so for the portion size. So, unless FFTB received a very different profile, it is hard to see that this criterion is satisfied. And it is impossible to see how this even matches up to the website’s claim:

a daily serving ensures your child’s intake of development promoting natural antioxidants and flavonoids.

We are using the usual understanding of ‘antioxidants’ here to refer to vitamins such as A, C and E^[10] and we are assuming their recommended serving size.

Which leaves the final criterion of “free from” etc. It is hard to see how that one criterion can be sufficient to base an endorsement on but it seems as if it is – which looks like egregious cherry-picking.^[11] Now, the FFTB endorsement isn’t specified or quantified. It is reasonable to assume that if people are aware that it means that a product is ‘low GL and low in sugar’ then they might, mistakenly, think that this is true of the dried cherries. They might also think that the much-vaunted Scientific Advisory Board of the FFTB guarantees some form of respectability, by association, for the more remarkable medical and health claims. And similarly for the Food Advisory Committee and the nutritional claims.

Even consulting the FFTB Food Audit Model (pdf) does not clarify the issue of why the dried cherries qualified. The model exacerbates the confusion because it introduces a different criterion (low salt) and modifies others to be less rigorous. It looks like the advertising for the endorsements highlights criteria such as low sugar and high in vitamins and minerals but these are not insisted upon in the food audit and not essential for accreditation.^[12]

This FFTB endorsement may be useful not only in the UK but overseas. It seems that various cherry producers have attracted FDA attention and criticism and have resorted to sleight-of-website to off-load the responsibility for health claims. We mention this because both the US marketing website that is used as a proxy to make health claims for cherries and the Cherry Active site in the UK make similar claims, and they both provide the same Cherry Nutrition Report: Cherry Active (pdf) and Choose Cherries (pdf).

Interestingly, although a company may be constrained from making health or nutritional claims for its products, there may be comparatively few restrictions on such claims being made or implied by the endorsement of a charity. So, it might make good business sense for a food or supplement manufacturer to purchase a charity’s endorsement because it may well permit it to make a string of health or medical claims, using the charity as its proxy. Charities have to obtain their funding from somewhere. But, if they can be used in this way, will charities further contaminate the public understanding of basic science? Is it acceptable to use them to promote outlandish concepts like this?^[4]

[H]idden hunger can not only damage and limit a child’s growth and intellect, but can also weaken their immune system

Is it acceptable for a charity to bestow the imprimatur of respectability of a product that has been deprecated by experts or for which the available evidence does not match the nutritional or health claims? It may benefit the charity but is it in line with its usual service remit? HolfordWatch wonders if it might be more appropriate to offer TRASH endorsements that are especially designed to meet the needs of Truthiness, Referenciness and Scienciness Hawkers.

Update June 26: I’ve just come across this explanation of how cherries are dried. Unless there is an independent analysis of a dried cherry product from a food laboratory, it seems unwise to extrapolate any nutritional information about cherries based on information about the fresh version. To me, this sounds very like the dried product has added sugar as well as its own sugars.

unlike grapes (dried into raisins) and plums (prunes), cherries have a low sugar content (the sugar acts as a natural preservative)…

“If you just dried the cherry, it would be tough and hard. To get it soft, you [have to] replace the water in the cells of the fruit with sugar solids,” Nugent said.

He devised a method similar to pickling that uses sugar instead of salt; it preserves the cherries and removes the juice. Then the juice is concentrated and returned to the cherries in a process called “infusing.” Then they’re dried again for four to five hours.

Notes

[1] Dr Hilary Jones is a long-standing ambassador for YorkTest.
Liz Tucker is one of YorkTest’s long-standing experts.
Angela Beescroft seems to work for YorkTest as one of their nutritionists.
Professor Peter Whorwell is one of the authors of the GUT paper that is endlessly cited by YorkTest in support of their products.
Dr Anton Emmanuel has also used YorkTest products in his research.
[2] Allergy UK on candida which is aka yeast overgrowth and said to be related to multiple chemical sensitivity. AUK argue that it should be considered for diverse symptoms.

In summary, yeast overgrowth should be considered in people who complain of bloating, wind, diarrhoea or diarrhoea/constipation, and who may also suffer lethargy, nasal symptoms, asthma, rashes / urticaria, and who have a history of repeated thrush of the mouth or vagina, lots of antibiotics, steroids or hormones.

[3] The circle here is that many nutritional therapists receive training that endorses the use of IgG tests for determining food intolerance. They recommend these tests to their clients and may receive commission for them. When the test comes back with some +ve results, the nutritionist may have an opportunity to offer guidance on the restricted diet and to sell on any supplements that may now be necessary because of the dietary restrictions.
[4] The accreditation process is not arduous. At least 3 members of the FFTB Food Advisory Committee review the manufacturer’s submission.
[5] There are remarkable claims for Cherry Active Kids:

Antioxidants play a vital role in the physical growth and mental development of children. A child’s full genetic potential for physical growth and mental development may be compromised due to subclinical deficiencies of micronutrients. This is commonly referred to as ‘hidden hunger’. This hidden hunger can not only damage and limit a child’s growth and intellect, but can also weaken their immune system leaving them vulnerable to develop frequent and more severe common day-to-day infections. CherryActive Concentrate (and Dried Cherries) is the perfect way to remove any hidden hunger, as a daily serving ensures your child’s intake of development promoting natural antioxidants and flavonoids. [Emphasis added.]

Ignoring the issue of ‘hidden hunger’, it does not seem as if this last claim can be true for the recommended 32.5g serving. There are no references to support the implication that otherwise well-nourished children in the UK are compromised by these “subclinical deficiencies of micronutrients”. It is probably that none of these claims would survive the scrutiny of the ASA but are permissible on the company’s website at present because websites fall under the remit of the Trading Standards departments.
[6] The Unfair Commercial Practices Directive (pdf) has some thought-provoking sections. E.g., Clause 17 of the 31 banned practices makes it illegal to make a false medical claim for a product or service which may curb the claims that manufacturers can make but it is unclear whether there is still a loophole that allows charities to say what they wish. However, where a charity is charging money for an endorsement, it is not established whether this changes the picture.
Clause 7.12 makes an offense of “misleading omissions”. – e.g., a nutritional therapist who fails to mention that research has shown that there is no evidence-base for a particular blood test where the omitted information would result in the “average consumer” acting differently – i.e., not purchasing the test.
Clauses 14.35 to 14.37 apply to “vulnerable consumers”, and places an obligation traders to take particular care with products aimed at this group. E.g., a nutritional therapist who claims that a food supplement might benefit people with mental health problems might find themselves crossing the boundary of the acceptable. This might be policed more rigorously for claims involving vulnerable child populations.
The Nutrition and Health Claims regulations substantially limit the claims that can be made without verification.
[7] Glycemic load is calculated by multiplying the glycaemic index of a food by the amount of carbohydrate per serving and dividing by 100.
[8] There may also be some controversy about the estimated glycemic index and load of the dried cherries: there is no indication that there has been a specific test to establish the GI and therefore GL of these dried cherries.
[9] We should mention that in vivo testing of GI sometimes yields a different result than one might expect from a calculation of the nutritional data. However, the website does not mention any in vivo testing which is why we performed a theoretical calculation.
[10] It is possible that they will deploy the non-conventional metric gambit of referring to ORAC units rather than what is commonly understood by antioxidants.
Professor UK Dietitian has kindly provided us with more information about the probably nutritional profile of these cherries. Vitamin A is only found in animal based products so the vitamin A as listed is more likely to be carotenes – alpha, beta and the like.
FSA database lists cherries as food 1096 in The Composition of Foods (spreadsheet). There is a group analysis of whole raw cherries that reports beta carotene as 25 mcg per 100g.
We should also point out that we are not being unduly picky about the nutritional profile. Post-menopausal women are advised that 1500mcg or higher consumption of retinol is not advisable.
[11] Oddly enough, the Health Products for Life portal still sports Patrick Holford’s photograph and it markets the CherryActive range, including these dried cherries but although it makes its own odd claims, it doesn’t make any claims about GL, low sugar or a fabulous vitamin and mineral profile. However, we are slightly at a loss to understand how the added apple juice concentrate doesn’t count as a source of added sugar.

CherryActive Cherries are made from CherryActive’s carefully selected Montmorency cherries infused with apple juice concentrate, a real pleasure for your taste buds and very healthy too! Cherry Active Cherries contain no added sugars, sweeteners…

[12] FFTB Food Audit Model (pdf) lists slightly different assessment criteria and loses some of the modifers.

1. Vitamins & Minerals
2. Essential fats
3. Low Glycemic load (GL)
4. Free from artificial colourings and flavourings
5. Low salt level

It states:

A product needs to fulfil at least criteria no. 4 and then two out of no.1, 2, 3 or 5 to gain approval

It is surprisingly easy for a dried fruit product to meet the low salt level requirement, particularly as the low sugar requirement has somehow disappeared, although heavily featured in the PR releases. However, we would still argue that even by the different criteria it is difficult to understand the accreditation of the dried cherries.