Candy: What is Moderate Consumption? Laura Shumow, MHS Director of Scientific and Regulatory Affairs

National Confectioners Association Major association representing the U.S. confectionery industry – small and large companies since 1884 Education and leadership in manufacturing, technical research, public relations, retailing practices, government relations, and statistical analyses Committed to science-based evidence and educational resources to convey role of candy as a treat in a healthy lifestyle

Candy in History & Culture Earliest confections date back to antiquity Cocoa used by Mayans >2000 years ago Celebratory food often given as a gift and part of holidays/traditions Candy has long been a part of celebrations of happy moments – as a special treat, a follow up to “trick” at Halloween, and a momentary indulgence. There is a place for “little pleasures” such as candy in an overall lifestyle that supports health, wellness and happiness. Candy certainly should not replace nutrient-dense foods in the diet; but it is important to help the public understand how to incorporate these little pleasures in moderation to support an overall healthy diet that balances caloric intake and physical activity.

What is the impact of candy on health and wellness?

Cross-Sectional Analyses of Candy Consumption and Health Studies of more than 15,000 U.S. adults and 11,000 children and adolescents from NHANES data showed no association between candy intake with: increased weight/body mass index risk factors for heart disease (blood pressure, blood lipids, etc) Risk factors for diabetes/metabolic syndrome (glucose levels, CRP, etc) O'Neil CE, Fulgoni VL, Nicklas TA. Association of Candy Consumption with Body Weight Measures, Risk Factors for Cardiovascular Disease, and Diet Quality in U.S. Adults: NHANES 1999-2004. Nutrition Research, 2011. 31(2):122-130. O'Neil CE, Fulgoni VL, Nicklas TA. Association of Candy Consumption with Body Weight Measures, Other Health Risk Factors for Cardiovascular Disease and Diet Quality in U.S. Children and Adolescents: NHANES 1999-2004. Food Nutr Res. 2011;55. doi: 10.3402/fnr.v55i0.5794 

Cross-Sectional Analyses of Candy Consumption Frequency and Health A 2012 study of >1,000 healthy people published in Archives of Internal Medicine showed men and women who ate chocolate more frequently had a lower BMI than those who ate chocolate less often. In 2013, a Nutrition Journal publication showed that frequency of total candy consumed by adults was not associated with risk of obesity/overweight, blood pressure, blood cholesterol levels or markers of insulin resistance Golomb et al. Association between More Frequent Chocolate Consumption and Lower Body Mass Index. Arch Intern Med. 2012;172(6):519-521 Murphy et al. Body weight status and cardiovascular risk factors in adults by frequency of candy consumption. Nutr J. 2013; 12 (1): 53.

Candy consumption in childhood is not predictive of cardiovascular risk factors in young adults: The Bogalusa Heart Study The objective of this study was to determine whether candy consumption in childhood was predictive of the presence of adverse levels of CVRF, including weight/adiposity measures, in young adulthood. O’Neil CE, Nicklas TA, Liu Y, Berenson GS. Candy consumption in childhood is not predictive of weight, adiposity measures, or cardiovascular risk factors in young adults: The Bogalusa Heart Study. Journal of Human Nutrition and Dietetics. 2013. (E-pub before print).

Study Methodology Candy was defined as chocolate bars or packets (e.g. Hershey bars or M&Ms), other chocolate candy bars (e.g. Snickers), or sugar candy (e.g. Lifesavers). Separate linear mixed models were used to detect relationships between candy at baseline and health biomarkers at follow-up. Models were adjusted for baseline values, BMI, age, gender, race/ethnicity, total energy, lifestyle variables (i.e. smoking status & alcohol use), and total energy intake. Because age and candy intake varied at follow-up, they were also included as covariates in each model. Candy (g/d) consumption at baseline and from the first follow-up survey was obtained from one day 24-hr dietary recall Candy consumption from the second follow-up was obtained via a food frequency questionnaire. Separate linear mixed models were used to detect relationships between candy at baseline and health biomarkers at follow-up.

Effect of candy consumption on cardiovascular risk factors (n=355)  CVRF at Follow-up Candy Baseline Candy Follow-up β±SE std β P-value BMI (kg/m2)* 0.005±0.006 0.04 0.329 -0.004±0.009 -0.02 0.608 Weight (kg)* 0.013±0.016 0.03 0.410 -0.020±0.025 -0.03 0.413 Systolic BP (mm Hg)** 0.005±0.012 0.02 0.674 -0.006±0.020 -0.01 0.776 Diastolic BP (mm Hg)** -0.018±0.011 -0.09 0.108 0.006±0.018 0.732 Total Cholesterol (mg/dL)** 0.062±0.039 0.08 0.116 -0.067±0.063 -0.05 0.288 LDL-C (mg/dL) ** 0.025±0.036 0.495 -0.005±0.058 0.00 0.935 HDL-C (mg/dL)** 0.017± 0.015 0.06 0.262 0.000±0.024 0.993 Triglycerides (mg/dL)** 0.133±0.082 0.10 0.106 -0.245±0.133 -0.10 0.066 Glucose (mg/dL)** 0.025±0.019 0.11 0.191 0.034±0.039 0.07 0.382 Insulin (µU/mL) ** 0.047±0.026 0.18 0.081 0.031±0.058 0.05 0.591 *Adjusted for, baseline DV, age, gender, race, gender * race, total energy, candy consumed at follow-up, smoking status, and alcohol, and length of follow-up. **Adjusted for baseline DV, age, gender, race, gender*race, total energy, BMI, smoking status, and alcohol, and length of follow-up. Abbreviations: β = beta coefficient; SE = Standard Error

Conclusions & Implications Levels of candy consumption reported by this study population were not predictive of CVRF. Consumption of nutrient dense foods consistent with dietary recommendations are important, but foods like candy can be added to the diet, in modest amounts, without potential adverse long term health consequences. More studies are need to confirm these results.

Why No Link Between Candy and Weight?

Candy containing chocolate 15.0 13.2 15.6 Percent consumers of candy and per capita intake of candy among Americans ages 2 years and older   Population Group Parameter 2+ y 2-18 y 19+ y Candy consumers, % Candy containing chocolate 15.0 13.2 15.6 Candy not containing chocolate 12.6 21.3 9.8 Total candy 22.8 29.6 20.6 Per capita candy intake, g 5.7 4.7 6.1 4.3 7.2 3.4 10.0 11.9 9.4 Source: What We Eat in America, National Health and Nutrition Examination Survey 2007-2010, day 1 dietary recalls. n=17,571 individuals ages 2 years and older, n=6,090 individuals ages 2-18 years, and n=11,481 individuals ages 19 years and older; breastfeeding children were excluded from the sample. Candy categories (candy containing chocolate, candy not containing chocolate) correspond to the What We Eat in America food categories; chewing gum was excluded from this analysis.

Total energy intake, kcal 2075 1907 2128 Per capita contributions of candy to total energy, fat and sugar intakes   Population Group Parameter 2+ y 2-18 y 19+ y Total energy intake, kcal 2075 1907 2128 Energy intake from candy, kcal 45.2 51.6 43.2 % of energy intake from candy 2.2 2.7 2.0 Total fat intake, g 77.6 69.9 80.0 Fat intake from candy, g 1.6 1.5 1.7 % of fat intake from candy 2.1 Total saturated fat intake, g 25.9 24.5 26.4 Saturated fat intake from candy, g 0.8 % of saturated fat intake from candy 3.2 Total sugars intake, g 120 127 117 Sugars intake from candy, g 5.7 6.7 5.3 % of sugars intake from candy 4.7 4.5 Total added sugars intake, tsp 18.5 19.1 18.3 Added sugars intake from candy, tsp 1.2 1.3 1.1 % of added sugars intake from candy 6.4 7.0 6.3 Source: What We Eat in America, National Health and Nutrition Examination Survey 2007-2010, day 1 dietary recalls. n=17,571 individuals ages 2 years and older, n=6,090 individuals ages 2-18 years, and n=11,481 individuals ages 19 years and older; breastfeeding children were excluded from the sample. Estimates reflect intake from all candy other than chewing gum; candy as defined by the candy categories in the What We Eat in America food categories (i.e., candy containing chocolate and candy not containing chocolate).

Moderation vs Deprivation Research suggests that forbidding certain foods may be counterproductive Dieting and restrained eating may lead to overeating and poor body weight control in children and adults It is more productive to promote moderation rather than restriction

Ongoing Research on Candy Restriction Penn State study evaluating the effects of parental practices regarding candy Preliminary results show that parental restriction of candy is associated with children’s lower self-regulatory control Studying strategies to promote consumption of candy in moderation Trial on the impact of chocolate restriction on consumption at Purdue in adults

Identifying Strategies to Promote Moderate Consumption Individual tactics - mindfulness, distraction techniques Package size, food environment Parental tactics – “limit setting” as opposed to restriction

Proposed definition of candy in moderation: 50-100 calories/day

Educational Tools to Promote Moderation www.candyusa.com/treatright

Industry Responsibility Efforts In 2013 The member of the National Confectionery Industry announced their voluntary commitment to pursue a key strategy geared to help your shoppers cut through the confusion of ‘what’s in the confectionery products’ by putting calories on the front of the pack. Under the voluntary “Treat Right” program, manufacturers of confections will begin putting calories on the front of packages which will accompany more detailed ingredient summaries already on the back of packages. Exempt from this program will be gift box items

QUESTIONS Laura.Shumow@CandyUSA.com