Transcript Slide 1

Archimedes’ Lever for the World of Food:
\The
Overall Nutritional Quality Index
(ONQI)
David L. Katz, MD, MPH, FACPM, FACP
Associate Professor, adjunct, Public Health Practice
Director, Prevention Research Center
Yale University School of Medicine
www.davidkatzmd.com
Iowa Dietetic Association
Des Moines, Iowa
December 4, 2008
The mess we’re in…
Adult Population
100%
Overweight / Obesity
Insulin Resistance
Diabetes Mellitus
Cardiovascular Disease
Time
And the mess our children WiLL be in…
100%
Overweight / Obesity
Insulin Resistance
Diabetes Mellitus
Time
Cardiovascular Disease
Writing on the Wall,
HOT off the presses-
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November 12, 2008
Child Obesity Seen as Warning of Heart Disease
 By PAM BELLUCK
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NEW ORLEANS — A
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new study finds striking evidence that
children who are obese or have high cholesterol show early
warning signs of heart disease.
What food can do…
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80% reduction in heart disease
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90% reduction in diabetes
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60% reduction in cancer
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and so on…
Katz DL. Nutrition in Clinical Practice, 2nd
Edition. 2008
How to get there from here:
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Pattern shift: 5 a day, by 3010
and/or
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Progress, one food choice at a time!
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but the supply of food for thought is indigestible…
Who is even looking out for…
things they never knew they never knew?
Sodium content per 100 calories?
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Sodium
73 mg
Sodium
100 mg
Sodium
233 mg
Sodium
131 mg
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Added sugar per 100kcal?
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Sugar
12 G
Sugar
11 G
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Nutrition Quiz – Peanut Butter
Which of these is more nutritious?
Nutrition Quiz – Peanut Butter
Answer: Regular Peanut Butter
A little nutty…
150mg
Reduced Fat
Peanut Butter
250mg
Total Carbohydrate/sugar
7g
15g
Added Sugar*
3g
4g
3g/0g
2.5g/0g
2g
1g
190/32g
190/36g
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Nutrient
Sodium
Saturated Fat/Trans Fat
Fiber
Calories
NuVal SCORE
Peanut Butter
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What?…FDA or IOM would have done:
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July, 2003
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Katz DL. A food supply for dummies. Op-Ed: Hartford Courant;
NY Newsday; etc. 10/03
Feb, 2006: If you want something done…
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and the rest is history…
ONQI Scientific Expert/Development Panel
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Chair: Dr. David Katz, Yale University School of Medicine
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Dr Keith Ayoob, Albert Einstein College of Medicine
Dr Leonard Epstein, University of Buffalo; inventor, Traffic Light Diet
Dr David Jenkins, University of Toronto; inventor, Glycemic Index
Dr Francine Kaufman, USC; Past President, American Diabetes Association
Dr Robert Kushner, Northwestern University
Dr Ronald Prior, Arkansas Children’s Nutrition Center, USDA HNRC
Dr Rebecca Reeves, Past President, American Dietetic Association
Dr Barbara Rolls, Pennsylvania State University
Dr Sachiko St. Jeor, University of Nevada
Dr John Seffrin, President & CEO, American Cancer Society
Dr Walter Willett, Harvard University
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16 invitations extended; 14 acceptances
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Project Coordinators: Debbie Kennedy, PhD; Zubaida Faridi, MD, MPH: PRC
Statistician/Data Analyst: Valentine Njike, MD, MPH: PRC
Dietitians: Judy Treu, MS, RD; Lauren Rhee, MS, RD: PRC
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Others consulted
ONQI Scientific Advisory Board
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Dr. David Katz, Ex Officio, Yale University
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Dr. Keith Ayoob, Chair, Albert Einstein College of Medicine
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Dr. Leonard Epstein, University of Buffalo; inventor, Traffic Light Diet
Dr. David Jenkins, University of Toronto; inventor, Glycemic Index
Dr. Sonia Caprio, Yale University
Dr. Rebecca Reeves, Past President, American Dietetic Association
Dr. Gail Frank, California State University
Dr. Eric Decker, University of Massachusetts; food science
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Process
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Extensive review of literature; prior initiatives/formulas
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Basic formula circulated in early 2006
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Based on DRIs; FDA Nutrition Facts; USDA MyPramid; Dietary Guidelines for
Americans; International standards
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Iterative revisions based on expert panel consensus (listserve
exchanges; conference calls)
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Trust, but validate:
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Face validity
Content validity testing
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e.g., R = 0.92
Criterion validity testing
Algorithm ‘finalized’ ~7/07
The ONQI AlgorithmNumerator
Fiber
Folate
Vitamin A
Vitamin C
Vitamin D
Vitamin E
Vitamin B12
Vitamin B6
Potassium
Calcium
Zinc
Omega-3 fatty acids
Total bioflavanoids
Total carotenoids
Magnesium
Iron
Denominator
Saturated fat
Trans fat
Sodium
Sugar
Cholesterol
•Universal Adjustors
Fat quality
Protein quality
Glycemic load
Energy density
•Trajectory Scores
•Weighting Coefficients
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Product details
Universal (quality) adjustors
 Fat quality
 Protein quality
 Energy density
 Glycemic load
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Categorical stipulations
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Pure foods vs. processed
Intrinsic vs. added sugars
Artificial sweeteners
Etc.
A trajectory score answers this question:
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How does the concentration of a given
nutrient in a given food compare to the
recommended concentration of that
nutrient in the diet overall?
Product: threshold values
Numerator Nutrients
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Fiber: ##
Folate: ##
Vitamin A: ##
Vitamin C: ##
Vitamin D: ##
Vitamin E: ##
Vitamin B12: ##
VitaminB6: ##
Potassium: ##
Calcium: ##
Zinc: ##
Omega-3 fatty acids: ##
Total bioflavanoids: ##
Total carotenoids: ##
Magnesium: ##
Iron: ##
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Denominator Nutrients
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Saturated fat: ##
Trans fat: ##
Sodium: 1.2*
Sugar: ##
Cholesterol: ##
Universal Adjustors
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Fat quality
Protein quality
Glycemic load
Energy density
Dietary Reference Intakes. IOM. 2006;
Dietary Guidelines for Americans, 2005
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Product: trajectory scores
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Sodium
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C3=sodium/energy/1.2;
Calcium
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Da1=calcium/energy/0.5;
Product: trajectory scores
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More, as warranted, than “either/or”-
C3=sodium/Energy/1.2;
if C3 =< 0.25 then C3=0;
else C3=C3;
Cn3= mathematically transformed C3
Weighting coefficients…
because a difference, to be a difference, must make a difference
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Applied to all trajectory scores
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Ws = severity
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Wp = prevalence
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Wr = relative impact / strength of association
Ws: severity coefficient
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Ordinal scale addressing severity of condition(s)
with which a nutrient is principally associated
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minor severity defined as contributing to pathology but not
debilitating or a cause of premature death, e.g. seborrheic
dermatitis
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moderate severity defined as contributing to chronic disability
not directly associated with premature death, e.g.
osteoporosis, obesity
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high severity defined as contributing to premature death, e.g.
cancer, heart disease, diabetes and stroke
National Center for Health Statistics, CDC,
2007
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Wp: prevalence coefficient
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Ordinal scale addressing prevalence of
condition(s) with which a nutrient is principally
associated, & frequency of nutrient influence
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uncommon
moderate
common
very common
National Center for Health Statistics, CDC,
2007
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Wr: relative impact coefficient
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Ordinal scale addressing strength of
association between nutrient and given
condition(s)
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modest impact/weak association
moderate impact/uncertain association
high impact/strong association
Dietary Reference Intakes, IOM, 2006.
Diverse other sources.
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Product: weighted trajectory scores
C3=sodium/Energy/1.2;
if C3 =< 0.25 then C3=0;
else C3=C3;
Cn3= mathematically transformed C3;
A3=Ws*Wp*Wr*Cn3
Differentiation, in the details
Citius, Altius, Fortius…
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AND??
ONQI formula
Something like:
(1+UA1)×(1+UA2)×(1+ WP1×WS1×WR1×(adjustedTS1)+ ------------------ +WP16× WS16×
WR16×(adjustedTS16 ))
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GL×ED×(1+WP1×WS1×WR1×(adjustedTS1)+ ---- +WP5×WS5×WR5×(adjustedTS5))
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Variables in Formula
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TS = trajectory score
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Wp = weighting coefficient, prevalence
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Ws = weighting coefficient, severity
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Wr= weighting coefficient, relative impact
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UA1= adjuster for biological quality of fat
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UA2= adjustor for biological quality of protein
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ED= energy density adjuster
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GL= glycemic load adjuster
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Adjusted= pertinent mathematical transformations
And in all its (gore or) glory: 12 pages of mind-numbing computer programming
Data source for the algorithm
For many products, the Nutrition Facts and Ingredient Statement provides
the necessary data to score products using the algorithm.
RECIPE
Recipe
Development
10 g
1 mg
2 mg
1 mg
.5 mg
24 mg
1g
.75 g
.5 g
135 mg
120 mg
100 mg
70 mg
40 mg
10 mg
WHEAT FLOUR
NIACIN
REDUCED IRON
THIAMINE
RIBOFLAVIN
FOLIC ACID
SOYBEAN OIL
SUGAR
COTTONSEED OIL
SALT
BAKING SODA
HF CORN SYRUP
SOY LECITHIN
NATURAL FLAVOR
CORNSTARCH
Nutrient
Profile
INGREDIENTS: ENRICHED FLOUR (WHEAT FLOUR, NIACIN, REDUCED IRON,
THIAMINE MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC
ACID), SOYBEAN OIL, SUGAR, PARTIALLY HYDROGENATED COTTONSEED OIL,
SALT, LEAVENING (BAKING SODA AND/OR CALCIUM PHOSPHATE), HIGH
FRUCTOSE CORN SYRUP, SOY LECITHIN (EMULSIFIER), NATURAL FLAVOR,
CORNSTARCH.
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High tech input-
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Idiot-proof output:
A Sampling of Scores
Beef & Poultry
Turkey Breast (skinless)
Chicken Breast (boneless)
Pork Tenderloin
Bottom Round Roast (Beef)
Flank Steak (Beef)
Breast
Veal Chop
Veal Leg Cutlet
Beef Tenderloin
Chicken Drumstick
Ground Sirloin (Beef 90/10)
Pork Chop (boneless center)
Chicken Wings
Ground Round (Beef 85/15)
Lamb Chops (loin)
Leg of Lamb
Ham (whole)
Ground Chuck (Beef 80/20)
Pork Ribs, Country Style
Beef Spareribs
Pork Baby Back Ribs
48
39
35
34
34
31
31
31
30
30
30
28
28
28
28
28
27
26
25
24
24
Seafood
Atlantic Salmon Fillet
Atlantic Halibut Fillet
Catfish Fillet
Cod Fillet
Tilapia Fillet
Oysters
Swordfish Steak
Prawns
Shrimp
Clams
Monkfish Fillet
Bay Scallops
Turbot Fillet
Lobster
87
82
82
82
82
81
81
75
75
71
64
51
51
36
Canned Vegetables
Produce
Apricots
Asparagus
Beans
Blueberries
Broccoli
Cabbage
Cauliflower
Kiwi
Lettuce
Mustard Greens
Okra
Orange
Spinach
Strawberries
Turnip
Carrots
Grapefruit
Pineapple
Plums
Mango
Potatoes
Red onions
Tangerines
Bananas
Corn
Grapes
Honeydew Melon
Rhubarb
Iceberg Lettuce
Bok Choy
Passion Fruit
Coconut
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
99
99
99
99
93
93
93
93
91
91
91
91
91
82
81
78
24
Del Monte Fresh Cut French Style Green Beans No Salt
Del Monte Fresh Cut Whole Leaf Spinach
Del Monte Fresh Cut Sweet Corn Cream Style No Salt Added
Del Monte Fresh Cut Whole Green Beans
Green Giant Extra Long Tender Green Asparagus Spears
Green Giant Cut Green Beans
Del Monte Organic Whole Kernel Corn
Green Giant Sweet Peas 50% Less Sodium
Le Sueur Very Young Small Sweet Peas
Green Giant Super Sweet Yellow & White Whole Kernel Corn
Del Monte Organic Sweet Peas
Veg-All Homestyle Large Cut Vegetables
Del Monte Fresh Cut Sweet Corn Cream Style
Green Giant Niblets Whole Sweet Corn
Progresso Artichoke Hearts
Aunt Nellie's Whole Ruby Red Pickled Beets
100
76
67
59
56
52
50
48
43
42
39
35
32
27
18
3
Frozen Vegetables
Birds Eye Frozen Cauliflower Floret plastic bag
Birds Eye Frozen Chopped Spinach box
Green Giant Frozen Broccoli Cuts steamable bag
Green Giant Frozen Cut Green Beans steamable bag
Birds Eye Frozen Peas polybag
La Choy Frozen Snow Pea Pods box
Birds Eye Steamfresh Frozen Brussels Sprouts steamable bag
Birds Eye Frozen Cooked Winter Squash box
Green Giant Frozen Mixed Vegetables steamable bag
Birds Eye Frozen Asparagus Stir Fry plastic bag
Birds Eye Frozen Green Beans & Lightly Toasted Almonds box
Green Giant Frozen Cauliflower & 3 Cheese Sauce plastic bag
Green Giant Frozen Creamed Spinach in Low-Fat Sauce box
Birds Eye Steamfresh Specially Seasoned Southwestern Corn
Green Giant Frozen Sweet Baby Peas and Low-Fat Butter Sauce
Green Giant Frozen Honey Glazed Carrots box
Green Giant Frozen Green Bean Casserole box
100
100
100
100
96
96
94
91
87
82
68
42
34
33
30
26
23
Cereal
Hodgson Mill Unprocessed Wheat Bran
Post Shredded Wheat Original
Kashi 7 Whole Grain Puffs
Kellogg's All-Bran
Kellogg's Special K Protein Plus
Quaker Shredded Wheat
General Mills Fiber One
Kashi Golean High Protein & High Fiber
General Mills Cinnamon Toast Crunch
Quaker Instant Oatmeal Original
General Mills Cheerios
Post Shredded Wheat Frosted
Kellogg's All-Bran
Post HealthyClassics Grape-Nuts
Post Honey Bunches Of Oats with Almonds
Kashi 7 Whole Grain Flakes
General Mills Kix
General Mills Wheaties
General Mills Whole Grain Total Raisin Bran
Post Healthy Classics Raisin Bran
Kellogg's Frosted Flakes
Kellogg's Corn Flakes
Post Fruity Pebbles
Kellogg's Mueslix
General Mills Corn Chex
Cream Of Wheat Instant Hot Cereal
Quaker Natural Granola Oats, Honey & Raisins
Kellogg's Rice Krispies
General Mills Basic 4
General Mills Lucky Charms
Kellogg's Corn Pops
Kellogg's Froot Loops
Kashi Strawberry Fields
Cap'n Crunch
Quaker Instant Grits Butter Flavor
Salty Snacks
100
91
91
76
60
56
52
47
40
39
34
31
31
30
29
29
29
28
27
26
26
25
24
24
24
24
23
23
23
23
20
17
11
10
6
Garden of Eatin No Salt Blue Tortilla Chips
Terra unsalted potato chips barbecue
Garden of Eatin Blue Tortilla Chips
Terra Gold Original Potato Chips
Snyder's Multigrain Pretzel Sticks Lightly Salted
Guiltless Gourmet Chili Lime Tortilla Chips
Tostitos Light Restaurant Style
Utz Baked Potato Crisps Original
Good health peanut butter filled pretzels
Doritos Baked Nacho Cheese
Frito-Lay Sun Chips Harvest Cheddar
Lay's Baked Potato Crisps
Baked Ruffles Cheddar & Sour Cream
Newman's Own Organic Pretzel Rounds Unsalted
Ruffles Thick Cut Original
Doritos Cool Ranch
Lay's Potato Chips Classic
Snyder's Pretzels Honey Wheat o
Sunshine cheez-it party mix
Newman's Own Organic Pretzel Rounds Salted
Fritos Corn Chips Original
Cheetos Puffs
Rold Gold Petzels Rods
Chex Mix Traditional
Doritos Nacho Cheese
Rold Gold Pretzel Sticks Fat Free
Pringles Reduced Fat Original
Ruffles Cheddar & Sour Cream
Cheetos Crunchy
Utz Potato Chips Barbecue
Combos Pretzel Cheddar Cheese
Bugles Original Corn Snack
Glutino Pretzel Twists Gluten Free
52
41
40
33
31
30
28
27
26
25
25
25
24
24
24
23
23
23
20
19
16
14
14
13
10
10
9
9
5
4
3
2
1
Proof in the Pudding (& elsewhere…)
Food Category
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Diverse (n=21)
Bread and Crackers (n=10)
Cereals & Granola Bars (n=10)
Dairy Products (n=9)
Fat/Oil (n=10)
Fruits (n=10)
Meat/Protein (n=10)
Snack Foods (n=9)
Spreads and Condiments (n=10)
Vegetables (n=10)
Rho
p-value
0.92
0.66
0.89
0.92
0.71
0.33
0.93
0.93
0.95
0.70
<0.001
0.04
<0.001
<0.001
0.02
0.36
<0.001
<0.001
<0.001
0.02
Under Review: Am J Health Promotion
The advantages…
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of continuous truth:
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For retailers
For manufacturers
For consumers-
Consumer Testing
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Qualitative: focus groups
Quantitative: Affinova
 Group 1: women, n = 454
 Group 2: men and women, n = 350
Percent of Respondents Answering “strongly agree” or “agree”
(n=454)
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The system would be useful in helping me make my purchasing decision:
93%
The rating system would affect the decisions I make about which foods to
purchase in the grocery store: 86%
I would be more likely to purchase a product that used the system versus
one that did not: 74%
I would be more likely to stop at a grocery store that used the system
versus one that did not: 66%
Consumer Testing: ONQI vs. Alternative (best,
better, good, no score)
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Which store would consumers select if both
systems were available nearby? (n = 350)
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Definitely/Probably ONQI
Either Store
Definitely/Probably Alternative
Neither Store
75%
20%
2%
3%
When science means business…
it needs to do business
One number.
One decision.
One food at a time.
Expert nutritional knowledge
in a single score - allowing
people to make well-informed
choices, one food at a time.
NuVal LLC
Company Overview
 NuVal
LLC officially formed in March 2008
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Originally named ONQI LLC
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Headquartered in Boston
 NuVal
LLC jointly owned by Topco Associates in Skokie, Illinois
Griffin Hospital in Derby, Connecticut
and
 ONQI
Science remains the property of Griffin Hospital and
is licensed to NuVal LLC
 Objective
of NuVal LLC: Commercialize scores from ONQI Science
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The NuVal Vision
Empowering people to eat better,
one well-informed food choice at a time,
wherever and whenever food is
purchased
and consumed.
NuVal con tempo
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Initial launch in supermarkets & on web: October, 2008
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Lead market launch: Price Chopper; HyVee
www.nuval.com
Ramp up: 9/08-3/09
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15 committed retailers, representing ~5,000 stores
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Finalizing contract with one of top 5 US retailers
Talks on-going with dozens of other retailers in US and Canada, representing thousands of additional stores
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Book series planned; Hachette Publishing
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Adaptations for total dietary scoring
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Condition-specific ONQI variants for diabetes, hypertension, heart disease, weight management, etc.
ONQI variants tailored to particular dietary needs and preferences, e.g., vegetarian, gluten-free, nut-free, etc.
Validation research: On-going; Harvard School of Public Health
Initial scientific manuscript: Am J Health Promotion, under review
Other Applications in the works: schools, federal programs
Engagement of food manufacturers: on-going
Compared to
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What?-
Nutrition Facts Panel (US FDA)
MyPyramid (USDA)
Keystone: Smart Choice
Food Standard Agency’s Nutrient Profile (UK)
Ratio of Recommended to Restricted Foods (US)
Nutritious Food Index (Australia)
Calorie for Nutrient Index (US)
Nutrimap (France)
Naturally Nutrient Rich Score (US)
Hannaford’s Guiding Stars (US)
Seal of approval systems: AHA; Whole Grains Council; etc.
Company-specific guidance systems: Sensible Solutions (Kraft); Smart Spot (Pepsi); Nutritional
Compass (Nestle); Choices (Unilever); etc.
Guideline Daily Amounts (GDA)
Etc.
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& so
what?...
UONIQUEI
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Completely objective; totally independent science
Comprehensive: beyond citius, altius, fortius
Continuous: fine differentiation
Satiety, by stealth
Holistic: of checkout counters, & annual check-ups
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If we can summarize the health of a person, we can summarize the
healthfulness of a food!
High performance engine, turn-key simplicity
Thank you!
David L. Katz, MD, MPH, FACPM, FACP
Director, Yale Prevention Research Center
Griffin Hospital
130 Division St.
Derby, CT 06418
(203) 732-1265
[email protected]
www.davidkatzmd.com