Some people wouldn’t eat the candy bar because of guilt; others might walk to burn off the calories. And of course, some people might not even notice the exercise message, or might not care about the information. That’s the problem with some public-health interventions: They affect people differently.
Of course, this is a fictitious example, because food packages don’t list “physical activity calorie equivalents,” or PACE. But this idea is being studied as a potential food label option, and it’s stirring up some controversy among health-care practitioners.
While some believe that PACE labeling is a clear way to express energy balance and to combat obesity, others see it as a food-shaming tactic that focuses too strongly on weight as a measure of overall health. I’m firmly in this latter camp, and I worry that PACE is merely another Band-Aid solution for society’s larger problems of unequal access to affordable food and health care.
In January 2016, the Royal Society for Public Health in the United Kingdom issued a position paper supporting PACE labeling for foods. A recent meta-analysis published in the Journal of Epidemiology and Community Health also supports the idea.
Amanda Daley, a professor of behavioral medicine at Loughborough University in the United Kingdom, led the team of researchers who looked at 14 previous studies on whether displaying PACE on food packages affected people’s choices. The studies were simulated online or in laboratories, not in real-world environments.
“We found that PACE labeling leads to a reduction of about 65 calories per eating occasion, or about 200 calories per day,” Daley says. The study did not examine whether exercise habits also changed.
Daley explains that an average daily deficit of 500 calories is required for weight loss, so 200 calories is a good start. “Add that to calorie-counting and some exercise, and PACE is one of many things that could help,” Daley says. She acknowledged that PACE alone will not curb obesity rates, nor is it meant to replace public-health advice or current nutrition information on food labels. It would just provide additional information in a way that may be easier for consumers to understand.
I spoke with several dietitians who agree that PACE provides clarity about energy balance. Kayla Womeldorff, a registered dietitian in Rochester, N. Y., works with adults who receive Supplemental Nutrition Assistance Program (SNAP) benefits. She believes PACE may be a more concrete concept than calorie-counting, but she also teaches her clients not to view exercise as a way of “earning” food.
New Jersey-based dietitian Erin Palinski-Wade, who specializes in weight management and diabetes, says PACE would be beneficial to her clients because it’s difficult for them to conceptualize what a certain calorie amount truly means in terms of energy; however, she’s quick to add that PACE isn’t helpful unless people learn about the quality of calories they eat.
“The key to making PACE a valuable tool for all consumers is to differentiate between high-quality calories that fuel the body with nutrition and energy versus empty sources of energy,” Palinski-Wade says.
That is, consumers need to understand that 200 calories from almonds provide a greater quantity of nutrients than 200 calories from cookies, no matter how much someone exercises. Unfortunately, the current research on PACE does not differentiate by type of calorie. So, if someone is buying a snack and compares cookies and almonds, both may have the same PACE label. But that doesn’t educate consumers as to why almonds are still the better choice for their higher nutrient value. They would have to look at the Nutrition Facts label to learn more, but studies show that many consumers have difficulty interpreting labels. Adding PACE won’t help with this.
Most of the dietitians I spoke with don’t like the idea of PACE. Many have moved away from a “weight-normative approach” to health care, which defines health in terms of weight, and have moved toward a more “weight-inclusive” public-health approach, which aims to reduce weight stigma, improve health-care access, help people appreciate their bodies, and educate about the enjoyment of eating well and being active.
Rebecca Scritchfield, a dietitian in Washington, worries that public-health initiatives like PACE will enhance people’s food guilt, and that the information will be seen as a judgment on their eating behaviors.
“For lasting well-being, public-health programs should help improve access to a variety of healthy foods and educate on healthy preparation methods,” Scritchfield says. “Programs should encourage people to exercise for its inherent value, not to burn off food that helped nourish the person who ate it. The best public-health programs will support the community, people of all sizes, with inspiring and helpful tools for self-care while increasing joy and decreasing shame.”
Dietitians also take issue with the idea that the “minutes of exercise” on PACE labels are estimated based on the average 175-pound male. Daley says that regardless of gender, the PACE numbers are all so close that they still offer merit as an estimate. After all, calories on food labels are really just an estimate, too.
But Texas-based dietitian Liz Brown thinks the label numbers will be inaccurate for most people. “Including PACE on food labels encourages disordered eating behavior and leaves out the fact that our bodies are not labs,” Brown says. Bodies are different shapes and sizes, and they will use energy differently, even if undertaking the same exercise. “I strongly disagree with using this sort of measurement on labels due to the psychological impact,” she says.
Dietitians who work in eating disorder treatment programs also object to PACE. They worry that people may use the PACE estimate as an exact number and get bogged down in the minutiae of obsessively counting every calorie or step in an unhealthy way.
Dietitian and personal trainer Julie Harris works with individuals with eating disorders, who often struggle with knowing the number of calories in a food item. She says adding PACE could intensify this struggle. Daley says there’s no evidence that this type of campaign would lead to eating disorders and believes it’s highly unlikely that would happen.
A January update on the Royal Society for Public Health’s website says it has moved away from PACE labeling, despite the new research, because of the negative consequences it may have on some groups of consumers. It warns: “For those wishing to pursue this type of labelling further, we emphasise the need for caution. Measures should remain sensitive to any potential negative impact they may have on vulnerable individuals, including those suffering from or at risk of eating disorders.”
Harris would prefer to see easy-to-understand food labels that promote health, not labels that just focus on weight. Her ideal label would downplay calories and make carbs, protein and fat equally important. (On Nutrition Facts tables, calories are larger and in bold font.)
Harris is also concerned that PACE amplifies the long-standing “calories in/out” approach to weight loss, which is a small piece of the obesity puzzle. “Individuals don't typically overeat because they don’t know how many calories are in a food item,” Harris says. “PACE doesn’t get to the core reason why individuals overeat or choose foods that are calorie-dense.”
She notes that when individuals work out in the name of weight loss or burning off calories, they don’t enjoy it or stick to it long-term. For this reason, she doesn’t think PACE will help people develop a healthy relationship with physical activity.
Quite simply, a PACE system would fail to educate people about choosing nutritious foods or exercising because it’s enjoyable. It would just add guilt that might force people to exercise, which isn’t a beneficial habit that has staying power.
Registered dietitian Cara Rosenbloom is president of Words to Eat By, a nutrition communications company specializing in writing, nutrition education and recipe development. She is the co-author of “Nourish: Whole Food Recipes Featuring Seeds, Nuts and Beans.”
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