N of 1 Part 5: A Different Question

The magic formula

My friend, Andrew Abrahams, puts the current “diet wars” situation this way:

1.  the n of 1 view:  what works for you is what works, this is all that matters, end of story.

2.  the Platonic view : this is how your body/metabolism works, and so this is what you should do and if it isn’t working you probably are not doing right.

I think many of us start off being interested in nutrition because we like to know stuff, and knowing stuff about how to be healthy and fit is really cool because then you get to look better in your bathing suit than most or you can solve health problems that others can’t or any number of other minor acts of smug superiority masquerading as an objective search for knowledge. When we start out, we usually are completely immersed in perspective #2, that there is a “right” way to eat and exercise. We figure out what the “right” way is through various forms of scientific investigation/reporting brought to us by experts and/or the media; we apply that magic formula to ourselves; and we wait for the magic results to happen. If we are young and unencumbered by reality, they usually do—no matter what formula for fitness and health we’ve chosen from the ones offered by the experts—and we congratulate ourselves for our hard work and strength of character.

Enter reality. Crying babies. Crazy work hours. Demoralizing paychecks. Chronic injuries. Insane parents. Needy friends. Crying, crazy, demoralizing, chronically insane, needy life partners (No, my dear sweet rockstar hubby, I certainly couldn’t have had you in mind when I wrote this.)

A little reality can drop-kick your magic fitness formula into outer space.

For many of us, somewhere along the line, the magic formula stops working, or we stop working at the magic formula, or a little (or a lot) of both.

Some of us respond to this by looking for the next—better, easier, quicker, more doable—magic formula. Some of us respond by working even harder at the magic formula we haven’t given up on—yet. Some of us give up looking and trying, because life is hard enough already.

But that doesn’t mean we’ve given up on the idea that there is a “right” way to go about being healthy. I was a low-fat vegetarian eater for 16 years because I thought it was the “right” way to eat. I’ve been a (mostly) low-carb, animal eater for 13 years, during most of which I thought I’d—finally—found the really “right” way to eat.

What I’d really found was a new and different way to be wrong.

I wasn’t wrong about the diet plan–for me. It helped me lose 60 pounds that I’ve kept off for 13 years without hunger, without a calculator, and without having to exercise more than I want to. What I was wrong about was being right. I was wrong about the magic formula—any magic formula.

[In blog posts yet to come, I'll tell you all the story of the woman who changed my perspective on everything.]

I hate being wrong (although goodness knows I’m really good at it, from years of practice). I really want there to be a formula, magic or otherwise. I like order, routine, facts, and answers. Gray areas make me woozy. That’s why I love biochemistry. It’s a game with nothing but rules that, literally, every body has to follow.

But, to quote Andrew Abrahams again, a detailed understanding of the minutiae of biochemical mechanisms doesn’t really help us in the big messy world of real people. Although everyone is subject to the same biochemical rules, how those rules play out in any given individual is difficult—perhaps impossible—to predict.

I salute the work that Gary Taubes and Peter Attia are doing with NuSI, which will focus on providing randomized controlled experimental evidence regarding nutritional interventions. The idea is to have both highly controlled experiments and more “real world” ones. Hooray for both. These experiments may help us understand how well certain nutrition interventions work—in experimental situations with a selected group of individuals. As awesome as this might be for a scientific pursuit, this science still may not be of much help for you personally, depending on how closely matched you feel your life and your self are to the experimental conditions—and it won’t provide any easy answers for the hardest issue of all, public health policy.

One big long experiment

Is there a way to round up our messy, individual realties into comprehensible information that will eventually translate into meaningful policy? Maybe. Andrew Abrahams and others in the ancestral health community have been tossing around the idea of “n of 1″ nutrition for a while. The basis for this approach is the idea that we all experiment. In fact, life is one big long experiment.

But how do we conduct these “n of 1″ experiments in a manner that

  • helps the person doing the experiment learn the right lessons (rather than be distracted by coincidences or random events)?
  • helps the clinician give better nutrition guidance not of the “one size fits all” variety?
  • helps the field of nutrition science develop more meaningful methods of investigation, especially with regard to long-term health and prevention of chronic disease?
  • helps us renegotiate the top-down, one-size-fits-all framework of current public health nutrition policy?

Andrew Abrahams had the brainchild of setting up a community for n of 1 nutritional experimentation to do exactly this.

As Andrew says, and I agree, individual characteristics, circumstances and history are tremendously important as far as choosing food and activity that works for you. His idea is to create a way to help people with this n of 1 experimentation so they can evaluate how their body will respond to changes and find what’s right for them.

The purpose of this community would be to capture the wide variety of attributes that may contribute to the outcomes for any individual, and provide modeling tools that can help people make the right decisions about what changes to make.

From a participant’s perspective, it would:

  • provide a way for you to observe and analyze personal health in an organized and (more or less) objective fashion
  • give direction, support, and structure to your own n of 1 experimentation
  • create a community of fellow experimenters with whom you could compare/contrast results

From a health professional’s perspective, it would:

  • provide a way to assist clients/patients in find what works best for them without a superimposing “it’s supposed to work this way for everyone” bias
  • create a set of algorithms for adapting common patterns to individualized recommendations and further experimentation
    • For example: A postmenopausal female who wants to lose weight may start one way and experiment in a series of steps that is different from, say, a 30-year old marathoner who wants to have a healthy pregnancy.

From a researcher’s perspective, it would:

  • create a way to structure and conduct experiments across a variety of nutritional (and other) factors
  • allow sharing and analysis of both pooled results and case studies/series of relevant community members or subpopulations with common characteristics
  • develop tools allowing one to interpret the community results for an individual context, make predictions and suggest “next steps”
  • contribute to the development of modeling systems for complex and interrelated inputs and outputs

A different question means a different approach to public health

I see the value of n=1 as a scientific pursuit because it will teach us to ask a very different question than the one we’ve been asking.  We’ve been asking, “What way of eating will prevent chronic disease in most/all Americans?” Typically, nutrition epidemiology is recruited to try to answer that question with the idea that there is some factor or factors (like smoking and lung cancer) that can be included/eliminated to reach this goal.  We’ve been so phenomenally unsuccessful at chronic disease prevention with our current population-wide model that I think a new framework of investigation is needed. Thus, n of 1 investigation changes the question to something more like: “What way of eating will bring improved health to you
now?”

As people make incremental changes toward shorter-term personal health goals, modeling tools can be used to map out “nearest neighbor” communities. These communities may be similar in terms of personal characteristics and health history, but also attributes relating to culture, region, lifestyle, ethnic and family background, education, income, etc. Over time, this information will reflect long term health outcomes built on a background of complex human traits interacting with complex human environments.

The complexity of n of 1 nutrition seems to be the very opposite of public health nutrition. And it would be naïve to think that the concept of n of 1 will not be at least partially co-opted by the food, drug, and research industries (“Try new Methylation Carbonation –for PEMT polymorphisms!”).  But by its very nature, n of 1 nutrition resists being turned into yet another “magic formula.”  More importantly, it reframes our current approach to public health nutrition along two very important lines:

First, it weakens the current public health message that a one-size-fits-all dietary recommendation is appropriate. This is especially important because it has been assumed for 30+ years that dietary recommendations that are normed on one population are equally applicable to other populations. A landmark study published in 2010 shows that African-Americans who consumed a “healthier” diet according to Dietary Guidelines standards actually gained more weight over time than African-Americans who ate a “less healthy” diet [1].

DQI stands for Diet Quality Index. Blacks with a higher DQI had more weight gain over time than blacks with a lower DQI. From [1]



Second, n of 1 nutrition emphasizes the need to return to a focus on provision of basic nutritional needs rather than prevention of chronic disease.  Balancing the complexity of the n of 1 concept (i.e. each human is radically different from another) with the simplicity of promoting/understanding essential nutrition (i.e. but each human shares these same basic needs provided by food) moves us away from the prevention model to the provision model. And the literature is pretty straightforward about what our basic nutritional needs are:

  • essential amino acids
  • essential fatty acids
  • vitamins and minerals
  • sufficient energy

Notice any thing missing on that list of essentials? As the Institute of Medicine’s Food and Nutrition Board says: The lower limit of dietary carbohydrate compatible with life is apparently zero” (DRI, Ch. 6, 275) [2]. This doesn’t mean you can’t or shouldn’t eat carbohydrate foods, or that some carbohydrate foods aren’t beneficial for some people or even many people. Indeed, some of my best friends are carbs. But dietary carbohydrate is not an essential component of our nutritional needs and never has been (although it is a fine source of energy if energy is what is you need and you aren’t wearing a 6-month supply on your backside, like I am). Rather, carbohydrate has been recommended as the source of the majority of our calories as a means of replacing the fat, saturated fat, and cholesterol that we’ve been told cause chronic disease.* This recommendation seems to have conveniently upsized the market for the industrialized and heavily-marketed foods—made mostly from corn, wheat, and soy—that take up most of the space on our grocery store shelves.

But I think the most significant ramification of the history of our Dietary Guidelines is not its effect on diet so much as the acceptance of the notion that something as intimately and intricately related to our health, culture, personality, lifestyle, family, and history as food can and should be directed—in a most comprehensive manner—from a place exceedingly remote from the places where we actually get fed.

Focus on community

While the ostensible focus of n of 1 nutrition is the individual, the real focus is the community. Advances in both biological and social sciences are increasingly focused on what are now considered to be the primary determinants of health status for an individual: that person’s genetic community and that person’s present community. What health behaviors you as an individual think you “choose” have already been largely determined by social factors: culture, socioeconomic status, education, etc. Those behaviors interact with genetic and epigenetic mechanisms that you didn’t have much choice about either. Although every individual has some control over his/her health behaviors, many of the health outcomes that we think of as being a result of “individual choice” are already largely predetermined.

One of the enduring myths of health care in the US is that there are some folks out there who “choose” poor health. Maybe there are, but I’ve met a lot of people in poor health, and I’ve never met anyone who deliberately chose it.

As we find virtual “nearest neighbor” communities in our n of 1 nutrition database, we may be able to use this information to assist real communities develop their own appropriate food-health systems. Despite our increasing diversity, much of America still clusters itself in communities that reflect shared characteristics which play leading roles in health and health behavior. Culturally-influenced food preferences and nutrition beliefs may be part of that community formation and/or may reinforce those communities. With scientific tools that embrace complexity and diversity, we can honor those characteristics that make one community (real or virtual) different from the next, rather than ignore them.

N of 1 nutritional approaches will give us a new way to think about public health nutrition and the individuals and communities most affected by nutrition policy. I’m proud to say that Healthy Nation Coalition will be supporting the project.

Up next:  My take on why nutrition is a feminist issue, or “I am Woman, hear my stomach growl.”

*While on a field trip to Washington, DC in January of 2010, I met Linda Meyers, one of the authors of reference #2 below. I asked her why carbohydrates were recommended as such a large part of our diet if there is no essential requirement for them. Her response was that the recommendation was based on prevention of chronic disease. I’m still not sure I get that.

References:

1. Zamora D, Gordon-Larsen P, Jacobs DR Jr, Popkin BM. Diet quality and weight gain among black and white young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2005). American Journal of Clinical Nutrition. 2010 Oct;92(4):784-93.

2. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (2005)

11 comments on “N of 1 Part 5: A Different Question

  1. BawdyWench says:

    I LOVED this installment. I’ts what I’ve been thinking for years, yet failed to realize it. You gave voice to a very important issue that faces us today, especially those of us who are female and past the age of 50.

    Thank you for being our voice!

  2. I think the n=1 viewpoint of “that’s all that matters” is merely a response to the fact that the community has failed many of us. It is really swim by oneself, or be dragged down by the community. I would love community too, but most days I am convinced that not only is it n=1 I heed, but I fear it is either that it is N=1 or that none of the n’s have coalesced into a big enough N for anyone else to consider.

    • Adele Hite, RD MPH says:

      “I think the n=1 viewpoint of “that’s all that matters” is merely a response to the fact that the community has failed many of us.” I would agree with this. Those of us who are natural skeptics, cynics, and troublemakers (or who have become ones because the formula/s we believed in have failed us–or us them) end up doing n of 1 experiments. I think other folks end up succumbing to every new Dr. Wizard of Oz that comes along–another way of experimenting individually en masse.

      We think that if we can collect enough n of 1 data however, the analytic and modeling tools available (this would be Andrew Abrahams territory, not mine) will allow us to find “communities” within the data. At the same time, we think that if we do this right, natural “virtual communities” may arise out of the act of collecting (maybe with some people acting as “guinea pigs” in trying new approaches and others following as their “fit” with that approach determines). This already happens in other online settings (yahoo groups), but without a lot of structure, or easily mapped direction. Both are ways to move from n to N.

      • It is like that old saying, “I lost ______, and eventually found it in the last place I looked.” Well, of course if something is found, most people wouldn’t quit looking. People who have been lucky at finding what they need after looking at a couple of places don’t understand those who are still looking everywhere. It is easy for the lucky ones to label the others as neurotic or something. I am not sure if any coalescing will work if the major institutions (yes, even the beloved paleo community) routinely exclude outliers.

      • Adele Hite, RD MPH says:

        Hmmmm. All very good points. But I wonder if there is merit in moving conceptually from “there is an umbrella and you must fit under it” to “there is no umbrella, but we can celebrate (and utilize) commonalities and honor differences.” Andrew–who is much much smarter than I am–has a better understanding and vision of the application of n=1 modeling; my primary appreciation for it–right now–is philosophical. But those philosophical underpinnings are important for just the reasons you mention.

        Certainly the language is likely to be co-opted by the institutions already in place. The USDA snatched up WAPF’s “nutrient-dense” phrase to exclude foods like eggs; it grabbed the vegatarian PCRM’s “plant-based” language to include foods like milk. We can be sure that we will see how the USDA is able help Americans create “individualized” nutrient-dense, plant-based meal plans–it’s only a matter of time.

  3. Kenny Gow says:

    A few questions, not necessarily related (to each other),

    a) How do we get people interested in teaching themselves about nutrition?

    b) What if we repealed the Dietary Guidelines and had no guidelines at all?

    c) Can you really generalize from n=1 to n=community?

    • Adele Hite, RD MPH says:

      I’ll take these backwards:

      c) n=1 to n=community is method of modeling data first, and a public health application later. It begins with clustering people with shared characteristics, perhaps finding commonalities in nutrition/lifestyle approaches, acknowledging individual variation/differences/exceptions. We actually take a rudimentary version of this approach in medical nutrition therapy: cancer patients would be a “community” with some general similarities (these communities could be subdivided into types of cancer), as well as individual differences.

      b) Yeah, that’s a good question. Right now we have so many federal nutrition programs that rely on the Guidelines to provide a nutritional framework for feeding those in need of nutrition support (or more cynically, to provide the rationale for feeding those in need of nutrition support cheap, industrial foods provided by commodity foods programs); the question is what would happen if the elimination of Guidelines created a sort of “power vacuum.” Ideally, the system should work from the ground up. We assist a community in determining its own health goals and the nutrition needs that meet them & then feed them accordingly, rather than have a remote, centralized system that determines that everyone should be fed the same way.

      a) It is my experience that most people do want to learn about nutrition–but I’m not sure they want to “teach themselves.” Nutrition may either seem overly simple (eat real food; calories in, calories out) or overly complicated (be sure to get your probiotic antioxidant flavonoids!)–both of which will stymie the learning process. It’s our job to figure out a way to make it “just right.”

  4. tess says:

    excellent post, Adele! i look forward impatiently, to your next article!

    • Adele Hite, RD MPH says:

      Thanks Tess. I got started thinking about women’s issues & nutrition in a Food & Culture class I took last semester–oh my goodness. Looking, together, at the past 30 years of (what passes for) “progress” in both of the areas gets my spandex unitard in a quite a twist ;p

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