A beautifully-written summary by Emily Contois regarding the recent Critical Nutrition Symposium held at UC-Santa Cruz. Organized by Julie Guthman, author of Weighing In, this symposium brought together food scholars from around the country (plus me) and invited us and the audience to participate in a thought-provoking and nuanced conversation about food, nutrition, culture, and ways of knowing.

Emily Contois

On March 8, 2013, I had the pleasure of attending the Critical Nutrition Symposium at UC Santa Cruz, organized by Julie Guthman, author of Weighing In. The event was spawned from a roundtable discussion at last year’s Association for the Study of Food and Society conference. The symposium brought together an interdisciplinary group of scholars to critically examine what is missing from conventional nutrition science research and practice, discuss why it matters, and brainstorm how to move forward in an informed and balanced way. What follows are a few of my favorite key ideas from the day’s discussions.

Adele Hite, a registered dietitian and public health advocate who is not afraid to ask big and delightfully confrontational questions regarding nutrition science, began the day by dissecting Michael Pollan’s now famous aphorism—Eat food. Not too much. Mostly plants. Step by step, she revealed the decades of revisionist myth…

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Vegetable Oil and Heart Disease: New news from the way-back machine

Since the 1970’s, we’ve reduced our sugar, salt, and saturated fat intake, and we’ve dramatically reduced our rates of smoking, high serum cholesterol and high blood pressure. At the same time, rates of chronic disease, including coronary heart disease, have increased—in some cases, dramatically.

The best that we can say is that since the 1970s, rates of myocardial infarction have decreased slightly—but only in white folks.

If the current health prescription is valid, then we should see dramatic differences in rates of disease and mortality between those who follow the prescription and those who don’t, and we should see clear and strong associations between “healthy” food choices and good health (because the same people eating a “healthy” diet are also taking care of their health in other ways). Yet this is not what we see.

Is it possible that our low-fat diet has removed some protective factors from our nutritional profile and exposed us to increased levels of nutrients that have negative impacts on health? I think it is, and a recent study in BMJ supports this notion.

I am a long-time admirer of one of the researchers, Daisy Zamora, and she is a good friend of mine. She’d been dropping hints about this great study she was working on for a while now—but was sworn to secrecy and now I know why. What she and her co-investigators have uncovered is data from a long-ago diet study, conducted from 1966-1973. It’s a decently large, well-run, randomized controlled trial that replaces saturated fat with safflower oil, a vegetable oil particularly high in one kind of PUFA—omega-6 (n-6) linoleic acid—and low in another kind of PUFA—omega-3 (n-3) alpha linolenic acid. The idea was that replacing “bad” saturated fat with “healthy” vegetable oil in men with premature coronary heart disease would improve survival. This did not turn out to be the case. For some reason, though, the original study only reported all-cause mortality and not deaths from cardiovascular disease and coronary heart disease.

Daisy and her co-investigators climbed into their way-back machine and this is what they found: Not only did the participants in the intervention group have an increased risk of all-cause mortality, but they had an increased risk of death from cardiovascular disease and coronary heart disease.

The blue line is the safflower oil group; the red line is the control group. To put it rather simplistically, the widening gap between the two groups means the intervention group died a lot faster than the controls.

Although the switch to safflower oil did lower total cholesterol, these reductions didn’t help those participants live any longer than those who kept eating saturated fat. In fact, as the authors note, “the increased risk of death in the intervention group presented fairly rapidly and persisted throughout the trial.”  (Hmm. Maybe this whole “cholesterol lowering” thing isn’t as important as we thought.)

Furthermore, the authors go on to point out that the relationship between linoleic acid consumption and increased mortality was particularly robust in smokers and drinkers, “suggesting that diets high in n-6 [linoleic acid] may be particularly detrimental in the context of oxidative stress induced by smoking and alcohol.”

Everyone knows that if you are a smoker you should quit and that alcohol should be used in moderation. But, with this evidence in mind, if you decided to keep on smoking and/or you want to drink immoderately, you may want to consider a breakfast of eggs and bacon rather than whole wheat toast and “heart healthy” margarine before you do.

The entire article is available online. Read it for yourself and see what you think.  Anybody besides me wondering how the American Heart Association will respond to this study?

Guest Post: James Woodward on Why Science May Not Be Enough

I’d like to introduce readers to a friend and fellow grad student, James Woodward. His undergraduate work was in economics at Ohio University, and he has a Master’s in public policy from the University of Kentucky. He is continuing at UK as a PhD student in public policy and administration. He and I have had some of the most thought-provoking email threads in any of my correspondence & I give him a lot of credit for helping me think through the economics and policy parts of food-health system reform puzzle. His post will serve as a bridge to my next series on “Eatanomics” which will explore how food, health, and the economy are intertwined. James would like everyone to know that all the disclaimers that appear on this page apply equally to what appears in this post. His views are his own, and as with the best of minds, he anticipates that most are subject to change. But he raises some very interesting questions—he’s nearly as long-winded as I am, but it is worth a read.

Why New Science May Not Be Enough – James Woodward

Before going into my social science background, I thought I would mention my professional background as it relates to food. It’s nearly as extensive as my academic background. I worked in fast food for about two years, a pizza place for about two years, a dining hall for a quarter, and, finally, a pseudo-Mexican restaurant for about two years. As a result, my feelings toward actual food and, especially, its preparation are fairly ambivalent at this point. The fact that I spent large amounts of time working with flour (I made tens of thousands of tortillas over the course of my tenure at the Mexican place) is rather ironic given my recent decision to avoid the stuff as much as possible.

Nutrition Science Initiative founders Gary Taubes and Peter Attia are hoping to give the public some solid science on food-health relationships.

My schooling in economics was concurrent with much of this work and my reasons for working these jobs had much more to do with my own economic situation than with any particular desire to work with food. But my background in economics and, now, public policy, leads to me to view the issue of food and nutrition policy a bit differently than many others writing on this topic. Many approach problems relating to nutrition and health in terms of their public health consequences. Others stress the fact that nutrition policy is the product of bad and/or misinterpreted science. Gary Taubes and Peter Attia just launched their organization, NuSI, to address, and hopefully settle, that particular aspect of this issue. Both lines of research clearly have their merits. Ultimately, though, I think what everyone is most interested in is influencing the behavior of individuals.

Contrary, perhaps, to Peter Attia’s quote from Richard Feynman in a recent blog post, I think there is a role for social scientists to play in understanding the many issues and controversies surrounding diet, health and public policy. Some of us in the social sciences are, in fact, sensitive to the difficulty of establishing real truths from the data available to us. Further, I do not think that social phenomena like behaviors and decision-making are reducible to physical and chemical relationships quite yet. How fitting that nutrition, and especially nutritional epidemiology, often bears more resemblance to bad social science than it does to any sort of ‘hard’ science.

Ignoring the controversy surrounding what it is that makes people fat and what constitutes an ideal diet, it would be hard to argue that people are making “good” decisions about what they are eating, given the high prevalence of (ostensibly) diet-related health problems in the United States, the most visible of which is obesity. Since most people buy their own food rather than growing or raising it themselves, food buying decisions tend to be highly correlated with food eating decisions. So, to me, the ultimate question is: “What influences food buying decisions?” Again, Gary and Peter have, with good reason, chosen to stress the importance of food consumption decisions being driven by good science. But there are clearly more factors that influence food purchasing decisions than a careful weighing of the scientific evidence. I would argue that such an approach to most decisions is, in fact, fairly rare. To the extent that Gary and Peter are ultimately trying to influence public policy, I think it is self-evident based on a reading of the history that policymakers are not that likely to employ such an approach either.

One of the many things besides science that may influence food purchasing and consumption.

This is why I tend to conceptualize the problem in the area of food and nutrition policy as one of bad information rather than attributing it purely to bad science. If one takes the time to dig, there is plenty of science which refutes the conventional wisdom regarding the relationship between diet and health. So, while no rigorous, carefully controlled studies have been performed to refute the conventional wisdom and/or confirm the “insulin hypothesis”, to use Gary’s term, there is already a lot of evidence to suggest that it is valid and plenty of evidence which refutes the conventional wisdom. Performing such a rigorous test of these competing theories is obviously warranted, given the importance of the implications for settling this debate, but there is no guarantee that the results will be convincing to skeptics, policymakers, stakeholders or the public at large.

Thirty-odd years ago policymakers perceived an obvious threat to public health (saturated fat) and saw a clear remedy (tell people not to eat so much saturated fat) which made it more or less a no-brainer to act on that information and tell people to avoid eating saturated fat containing foods. Since then, those original beliefs about diet and health have had time to percolate and become more or less embedded in how most people think about what they eat. Adele and I have talked a little bit about overcoming our own biases when we decided to eat differently, biases that we were not necessarily aware we had in the first place.

How you spend your food dollar may depend on how many food dollars you have to spend.

There are more factors that influence food purchasing decisions than just beliefs about how that food will affect one’s health. Taste, culture, geography, morality, ethics, politics, and socioeconomic status are just a few observable characteristics of an individual that might affect what he or she decides to eat. In many people’s minds, there is very little conflict between these concerns and health-related ones. For example, there is a perception that following a vegetarian lifestyle is good for one’s body, one’s soul, and the environment compared to a diet based around animal products. Upon closer inspection, however, there is a great deal of ambiguity to this belief in all three spheres. Similarly, many athletes seem to be operating under the impression that carbohydrates are required to perform at a high level. Peter’s well-documented experience calls that belief into question. Breakfast is often lauded as the most important meal of the day in the United States yet I frequently snub it to no ill-effect. And so on.

I think it is important to keep these biases in mind when thinking about we’d like to go about changing behavior. It is tempting to think “if only the science were better” people’s behavior would change. This is clearly not enough, in my mind anyway. It is just as important to be convincing as it is to be right. If/when NuSi successfully settles this debate and has the biggest names in the field to back up its research; there is still the matter of convincing everyone else. NuSi does acknowledge this aspect of the issue, though I am interested to see how it is addressed in practice. There are the cognitive biases of all the other scientists to contend with. There are also the material and non-material incentives that seem to be ingrained in many of the stakeholders involved in this particular area of policy. For example, it has been noted elsewhere that stressing the importance of calories is convenient for those involved in the production of food since doing so means no particular foods (e.g., wheat and sugar) are likely to be admonished against because of their unique effects on the body per se but, rather, because of their caloric content. I have to imagine that such firms will do their very best to refute any evidence that says otherwise and may hire their own experts to do so.

In a “calories in, calories out” world, there’s room for all foods in a “healthy” diet.

Beyond the obvious material costs to stakeholders of changing the current nutritional paradigm are the much more difficult to quantify costs of changing people’s beliefs about such things. Despite taking a nutrition course years ago (for an easy science credit, I will admit), I did not have particularly strong thoughts about nutrition prior to about a year and a half ago. I knew I made less than optimal choices about what I ate (according to conventional wisdom that is) but I mostly ignored those concerns since my health seemed fine (more or less). It was therefore fairly costless for me to change my mind about how I approach my diet after the conventional wisdom failed for me. Physicians and dietitians are not like me, however. Many of them have devoted years of their lives to dispensing information and advice that they believe to be correct and helpful. Faced with an opposing and incongruent view, it is perfectly understandable that they would be very resistant to the implication that they have been misleading their patients. In a less extreme form, I am sometimes asked by friends and acquaintances for my thoughts relating to diet and health and then, after giving them, met with resistance and facts or beliefs that supposedly refute my position(s). Most of these people are not experts on this topic but, like most people, they need some justification for what they believe.

So what is my point in all this? It is probably not breaking news that people’s eating decisions are not purely based on a careful reading of the scientific evidence. Better science is probably a necessary part of making the case but I do not think it will be sufficient to affect the type of change that many people in the ‘Paleo’ or ‘Ancestral Health’ communities (or whatever other term you prefer) would like to see. As mentioned, most people are averse to the notion that their beliefs are wrong and, in my experience, will try to come up with some reason for why that is not the case, sometimes resorting to questionable sources for support. This is human nature, I think– cognitive dissonance perhaps, to borrow a term from the psychologists. Based on what I can see, most people are not even willing to entertain the idea that there is a controversy or room for debate about these competing paradigms. Especially skinny people.

I think this state of affairs needs to change if further research is to bear any fruit in the form of affecting individual behavior and/or public policy. Fortunately, there are many bloggers writing on this topic, all bringing their own perspectives to the table. The challenge will be finding enough common ground to get this message to a larger audience so that we get an actual public debate going. I read the New York Times ‘Health’ section fairly regularly (as a barometer for this type of thing, not necessarily for good information) and I am not seeing it so far. It would be a real shame if all that came of this renewed interest in an old paradigm was a relatively minor reduction in the prevalence of obesity.

What Simon Doesn’t Say: An Expose with a Hidden Agenda

The Academy of Nutrition and Dietetics (AND) is squirming over a recent report written by Michele Simon of Eat Drink Politics that address ANDs corporate sponsorship program. The president of AND warns members not to believe everything they read and to mind the source (I supposed the assumption is RDs would be too sheep-like to do otherwise? Good thing Daddy Sheep warned us!), saying  ” . . . the majority of the report consists of publicly available facts filtered through the author’s opinions. She is of course entitled to her opinions. But opinions are not facts.”

I’m no fan of the Academy of Nutrition and Dietetics (AND), although they haven’t yet revoked my membership. I’m also no fan of industrialized food, although I do think the food industry has an important role to play in reforming our food-health system. I am also not a big fan of hypocrisy, which is why I have a good bit of trouble with the report, entitled Are America’s Nutrition Professionals in the Pocket of Big Food?

The answer is—I believe—a resounding “yes,” and Healthy Nation Coalition has explored how this compromised position extends not just to the food industry but the USDA itself. Clearly, the AND is an industry-friendly organization, and the USDA relies on AND-trained dietitians to confirm its own industry-friendly guidelines.

While I applaud Simon’s efforts to hold the AND more accountable for its relationships with industry, AND leadership is correct in pronouncing Simon’s reporting as one-sided and biased.  Simon is happy to slam the health-washing, cultural insensitivity, and hidden agendas of food manufacturers and the Academy, but if the propaganda, insensitivity, and agendas are vegatarian*—well, then she’s just fine with it, thank you very much.

“Healthy” smoothies are okay with Simon; meaty cheesy Big Macs are not.

Simon complains that “the banners at the McDonald’s booth showed images of healthy foods like smoothies,” but didn’t show McRibs and Big Macs. The implication, of course is that “healthy” smoothies” (with 78 grams of sugar and 4 grams of protein) aren’t so bad—even if they are from McDonald’s—compared to those meaty, cheesy foods like a Big Mac. Never mind that your body actually needs the protein that a Big Mac can provide and has little use for the 78 grams of sugar in a smoothie, except for fat storage.

How dare the Dairy Council target lactose-intolerant African-Americans! Every one knows all African-Americans would be healthier on a vegan diet . . .

Simon quotes an RD who points out that it is culturally inappropriate for the National Dairy Council to target African-American and Hispanic communities, considering the high rates of lactose intolerance in those populations, a remark with which I fully agree. Simon then goes on to complain about the inappropriateness of the Pork Board handing out educational material at “a nutrition conference where almost no countering information could be found about how a meat-centered diet can lead to chronic disease”?  In fact it would inappropriate to provide such “countering information” as the declaration that a meat-centered diet leads to disease is an ideological stance and not a scientific one. I would go on to add that it is also a culturally-insensitive stance, as pork is at the center of not only African-American and Hispanic food culture (barbeque, chorizo), but Chinese and Eastern European cuisine as well (lup cheong and kielbasa). It seems cultural sensitivity is fine if it means we can take away meaty, cheesy foods—but not when such sensitivity would allow them.

It’s not culturally insensitive to ban pork products–like these lup cheong– from a healthy diet; we’re just doing everyone a favor.

Simon’s take on the not-so-hidden relationships between the AND and the food industry is well-trod ground as she herself acknowledges, but to Simon some associations are apparently more odious than others:

In 1995, New York Times reporter Marian Burros wrote about criticisms of the [AND] for taking funding from industry groups such as the Sugar Association, the Meat Board, and companies such as McDonald’s, CocaCola, and Mars. According to Burros: “Nothing negative is ever included in materials produced by the association, a fact that critics attribute to its link to industry.” In that same article, veteran sustainable food advocate and Columbia University Professor Joan Gussow noted that giving money to registered dietitians is how industry silences its critics.

Simon pointedly calls out the National Cattleman’s Beef Association as an “especially loyal” sponsor. But if giving money means AND will only say positive things about your food product, it’s difficult to explain AND’s resounding endorsement of vegetarian and vegan diets, with “tips of the day” like “Endless Meat-Free Options” and articles that show you how to “Build Muscle, No Steak Required,” plus the promotion of stories such as “All Red Meat is Bad for You” in their daily newsletter. If I were the Beef Association, I’d want my money back.

Private consulting firms that have a “good” agenda don’t need to be held to the same levels of transparency as the “bad” ones.

I fully commend Simon’s calls for transparency, but the transparency knife cuts both ways. The AND/industry report was authored by Simon under the auspices of Eat Drink Politics, a self-described (by Simon) “industry watchdog” group that is also a “private consulting firm.” As such, while Simon is willing to disclose some of its clients, she states that “Some of our clients and funders prefer to remain anonymous for various reasons and we respect those wishes” (emphasis mine). So while she accuses the International Food Information Council of being “an industry front group” (which I think is pretty accurate), we can’t really tell who or what Eat Drink Politics is a “front” for, although we can take an educated guess.

The Eat Drink Politics website alerts us to an alarming situation regarding Deceptive Health Claims:

“The food industry has a challenge on its hands. Most health experts agree that the optimum diet is one based mostly on whole, plant foods, the kind that come from nature and not a factory. So, to convince Americans they can still eat their favorite meat, cheese, soda and junk food, many companies are using meaningless labels such as “all-natural” and engaging in other deceptive marketing practices” (emphasis mine).

Yup, meat and cheese—that’s about as un-natural as it comes.

It doesn’t take a rocket scientist to look through the science and figure out that “most health experts” don’t actually agree that the “optimum” diet is based mostly on whole, plant foods (actually I’m pretty sure it just takes a journalist, specifically Gary Taubes). It’s also pretty easy to figure out what Simon’s idea of a “whole, plant food” diet is:

“A diet based on whole plant foods minimizes or eliminates all animal products, including meat, poultry, fish, dairy, eggs, and their byproducts.”

Can you say—vegan?

Simon goes to great lengths in her book Appetite for Profit to deny that she has any vegan agenda, as she has been accused of by the Center for Consumer Freedom (a group Simon depicts—again, accurately, in my opinion—as a food and beverage industry front group).  She’s clearly sensitive to the fact that the word “vegan” is too loaded with negative connotations to actually use it when she suggests that “a diet that resembles my own would be optimal for most people.”

She accuses Center for Consumer Freedom of keeping its corporate sponsorship anonymous in order to engage in more provocative PR claims and of manipulating language to make it look like she’s pushing a personal agenda. But she seems pretty comfortable with keeping her own sponsors anonymous, with using provocative claims to alarm the public, and with using consumer-friendly language to gloss over aspects of her own personal biases that the public may find off-putting. I guess she figures it’s okay because she’s believes she’s got “decades of accepted nutrition science” and a “scientifically supported view” on the side of her personal nutritional biases.

I think Simon’s 5 recommendations to AND are long overdue. There is no doubt that AND would benefit from increased transparency; more input from members; sponsorship guidelines; an elimination of corporate-sponsored education; and stronger policy leadership.

But I cannot support is what I think is Simon’s most disturbing suggestion, that AND commit itself to policy action now—specifically taxation of sugar-sweetened beverages**—before a full review of scientific evidence and long-term implications can be ascertained.

According to Simon, “not every policy issue or decision can wait for months (or years) of committee review and analysis.” On the contrary, I would argue that more policy decisions that attempt to manipulate the health behaviors of Americans by relying on unproven assumptions about the relationships between food and health can and should wait for months or years or indefinitely, until consistent, quality experimental data is obtained or until observational data reveal consistent and unmistakably-high risks. Right now, the health crisis that Simon seems intent on addressing (and I applaud her intentions, if not her methods) is at least in part a result of sweeping changes made to our food system 35 years ago without such evidence in hand.

Simon’s unquestioning belief in her own nutritional agenda is a result of that policy experiment, but it isn’t the solution. It’s time we stop trying to change the eating habits of our fellow Americans—which is the underlying intention behind taxing soda and believing that a diet that resembles your own is best for everyone else—and start trying to change the regulatory, economic, and political framework that restricts access to both the food and the knowledge that individuals need to make their own decisions about their own health.

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In case you missed my interview with Bob Fenton, a fellow blogger who has type 2 diabetes, you can find it here: 

Adele holds forth on diabetes, dietetics, and why the refusal to admit the limitations of our nutrition knowledge is a dangerous thing.

Next up is a guest post from a friend and fellow graduate student, James Woodward, whose background in economics and public policy gives him a rather different perspective on how we might go about accomplishing the task of reforming our food-health system.  It will also provide a bridge to my next series on “Eatanomics” which will explore how food, health, and the economy are intertwined. 

*”Vegatarian” is a term I use to indicate veganism disguised as vegetarianism. While lacto-ovo-vegetarian dietary patterns are complete and perfectly healthy, vegan diets must rely on fortification or supplementation to be complete, as acknowledged by the promoters of such diets (just read the “fine print”).

**Sugar-sweetened beverages are usually pretty nutritionally useless, but we simply don’t know what sort of unintended repercussions a soda tax will have, or where to draw the taxation line. One study has shown that beer-drinking households responded to a six-month soft drink tax by buying more beer.

Not Just Science: Nutrition & Politics

Now that food–along with religion and politics–has joined the list of things you don’t talk about with friends, I thought I’d do my post-Election day best to offend everyone equally by highlighting just how political food and nutrition is these days.

I like to try to pass myself off as generally apolitical (on principle, I refuse to vote straight-ticket anything—but it could be I’m just a control freak who likes filling in all the bubbles myself). If forced to confess, underneath it all I’m a bleeding-heart liberal who wants to save trees and whales and who tends to blame the world’s ills on old white dudes (even—or especially –the one I’m married to).

But there’s another subtlety (and don’t tell my bleeding-heart liberal friends or they won’t invite me to anymore parties): I’d vote for ANYONE who was serious about fixing our food-health system, but—politically-speaking—who is going to do that?

Restructure subsidies, agricultural insurance, and agricultural financing to support small farmers rather than giant agribusiness? Who would do this? Democrats like feeding the excess corn, wheat, and soy commodities to the hungry people in America who are getting fatter and sicker by the minute as a result (It’s healthy!). Republicans like the big businesses that control those commodities. Everyone says they care for small farmers but no one does anything about it.

Federal nutrition program foods: plenty of soybean oil, corn syrup, gluten, and sugar, with a little arsenic thrown in for good measure

Modify food safety regulations to take into account size and type of operation? Democrats are all about protecting the public and regulating industry, but they are also all about “protecting” the public from the raw milk that those stupid Americans are stupid enough to drink. Republicans are more likely to support the dairy industry–the folks with the vested interest in outlawing raw milk–but also more likely to say the government shouldn’t be telling stupid Americans what they should and shouldn’t drink.

Somebody needs to tell Michelle that “moving more” makes kids hungry more; nothing wrong with that, but they’re not gonna “eat less” as a result.

End the one-size-fits all dietary recommendations? Thank you Michelle Obama for giving renewed vigor to the physiology-defying “eat less, move more” concept. Thank you, giant mom-and-pop-squashing Walmart, for playing right along.

You don’t like Obamacare? You do like Obamacare? You’re both right. Health reform is a joke until we focus on preventive measures that begin with feeding everyone adequate essential nutrition, not preventing chronic disease with foods that don’t prevent chronic disease.

Republicans believe that obesity is a personal responsibility; food and lifestyle choices by the public should not be interfered with by the government. Except when it comes to whether or not the public can know what is actually in the food they choose, in which case, the right to free speech when it comes to putting “health” claims on cereal boxes becomes the right to abstain from speech when it comes to putting GMO information there.

Democrats believe that it is up to the government to intervene in the market when personal choices become a public concern. So Democrats are out to make the “healthy choice” (a phrase that is an embarrassment to true meaning of both words) the easy choice for those poor stupid fat people out there who are too lazy and gluttonous to take care of their own health, never mind that the Democrat’s idea of “healthy” and “choice”  is limited to the USDA/HHS definition of both.

Republicans support the soda industry’s desire not to be taxed. Democrats are hoping butter and meat will be taxed next.

Thank goodness for the Libertarians—who are hard at work legalizing pot so the nation can now get the collective munchies. Watch for the Democrats to insist on restricted access to McDonald’s for those with medical marijuana prescriptions, while the Republicans fight for Monsanto’s right to patent all cannabis seeds grown anywhere ever by anyone. That backyard plot of weed will only be legal for about ten minutes before the Democrats start regulating the fun out of it and the Republicans hand everyone’s right to get stupid over to ConAgra.

Meanwhile, the rich get richer, the poor get fatter and sicker, and we all—rich and poor and middle-class alike—waste precious time, money, and attention on nutrition recommendations that support ideology and industry and do little for our nation’s very real health crisis. Politicians like Nixon and Clinton have undermined the nation’s ability to believe that any politicians can be trusted;  advice from the USDA/HHS, Ornish, and Atkins have done the same for nutrition. It’s a wonder we don’t all turn on, give in, and pig out.

Why Race Doesn’t Matter in Nutrition Policy

This is the first of a series looking at what does and doesn’t matter when it comes to nutrition policy. When I started out on this adventure, I thought that science would give me the answers to the questions I had about why public health and clinical recommendations for nutrition were so limited. Silly me. The science part is easy. But policy, politics, economics, industry, media framing, the scientific bureaucracy, cultural bias—now that stuff is crazy complicated. It’s like an onion: when you start peeling back the layers, you just want to cry. I am also honored to say that this post is part of the Diversity in Science Carnival on Latino / Hispanic Health: Science and Advocacy

When we began investigating relationships between diet and chronic disease, we didn’t pay much attention to race. The longest-running study of the relationship between dietary factors and chronic disease is the Framingham Heart Study, a study made up entirely of white, middle-class participants. Since 1951, the Framingham study has generated over 2 thousand journal articles and retains a central place in the creation of public health nutrition policy recommendations for all Americans.

More recent datasets—especially the large ones—are nearly as demographically skewed.

The Nurses’ Health Study is 97% Caucasian and consists of 122,000 married registered nurses who were between the ages of 30 and 55 when the study began in 1976. An additional 116,686 nurses ages 25 – 42 were added in 1989, but the racial demographics remained unchanged.

The Health Professionals’ Follow-up Study began in 1986, as a complementary dataset to the Nurses’ Health Study. It is 97% Caucasian and consists, as the name suggests, of 51, 529 men who were health professionals, aged 40-75, when the study began.

The Physicians’ Health Study began in 1982, with 29, 071 men between the ages of 40-84. The second phase started in 1997, adding men who were then over 50. Of participants whose race is indicated, 91% are Caucasian, 4.5% are Asian/Pacific Islander, 2% are Hispanic, and less than 1% are African-American or American Indian. I have detailed information about the racial subgroups of this dataset because I had to write the folks at Harvard and ask for them. Race was of such little interest that the racial composition of the participants is never mentioned in the articles generated from this dataset.

Over the years, these three mostly-white datasets have generated more journal articles than five of the more diverse datasets all put together.* These three datasets, all administered by Harvard, have been used to generate some of the more sensationalist nutrition headlines of the past few years–red meat kills, for instance–with virtually no discussion about the fact that the findings apply to a population–mostly white, middle to upper middle class, well-educated, health professionals, most of whom who were born before the atomic bomb–to which most of us do not belong.

Shift in demographics in past 50 years;
predicted shift in next 50 years

Although we did begin to realize that race and other characteristics might actually matter with regard to health (hence the existence of datasets with more diversity), we can’t really fault those early researchers for creating such lopsided datasets. At that point, not only was the US more white than it is now, scientific advances that would reveal more about how our genetic background might affect health had not yet been developed. We had not yet mapped the human genome; epigenetics (the study of the interaction between environmental inputs and the expression of genetic traits) was in its infancy, and biochemical individuality was little more than a glimmer in Roger Williams’ eye.

Socially, culturally, and I think, scientifically, we were all inclined to want to think that everyone was created equal, and this “equality” extended to how our health would be affected by food. Stephen Jay Gould’s 1981 book, The Mismeasure of Man, critiqued the notion that “the social and economic differences between human groups—primarily races, classes, and sexes—arise from inherited, inborn distinctions and that society, in this sense, is an accurate reflection of biology.” In the aftermath of the civil rights movement, with its embarrassingly racist behavior on the part of some representatives of the majority race and the heartbreaking violence over differences in something as superficial as skin color, it was patently unhip to suggest that racial differences were anything more than just skin deep.

But does that position still serve us now?

In the past 35 years, our population has become more diverse and nutrition science has become more nuanced—but our national nutrition recommendations have stayed exactly the same. The first government-endorsed dietary recommendations to prevent chronic disease were given to the US public in 1977. These Dietary Goals for Americans told us to reduce our intake of dietary saturated fat and cholesterol and increase our intake of dietary carbohydrates, especially grains and cereals in order to prevent obesity, diabetes, heart disease, cancer, and stroke.

Since 1980, the decreases in hypertension and serum cholesterol—health biomarkers—have been linked to Guidelines-directed dietary changes in the US population [1, 2, 3, 4].

“Age-adjusted mean Heart Disease Prevention Eating Index scores increased in both sexes during the past 2 decades, particularly driven by improvements in total grain, whole grain, total fat, saturated fatty acids, trans-fatty acids, and cholesterol intake.” [1]

However, with regard to the actual chronic diseases that the Dietary Guidelines were specifically created to prevent, the Dietary Guidelines have been a resounding failure. If public health officials are going to attribute victory on some fronts to Americans adopting dietary changes in line with the Guidelines, I’m not sure how to avoid the conclusion that they also played a part in the dramatic increases in obesity, diabetes, stroke, and congestive heart failure.

If the Dietary Guidelines are a failure, why have policy makers failed to change them?

It is not as if there is an overwhelming body of scientific evidence supporting the recommendations in the Guidelines. Their weak scientific underpinnings made the 1977 Dietary Goals controversial from the start. The American Society for Clinical Nutrition issued a report in 1979 that found little conclusive evidence for linking the consumption of fat, saturated fat, and cholesterol to heart disease and found potential risks in recommending a diet high in polyunsaturated fats [5]. Other experts warned of the possibility of far-reaching and unanticipated consequences that might arise from basing a one-size-fits-all dietary prescription on such preliminary and inconclusive data: “The evidence for assuming that benefits to be derived from the adoption of such universal dietary goals . . . is not conclusive and there is potential for harmful effects from a radical long-term dietary change as would occur through adoption of the proposed national goals” [6]. Are the alarming increases in obesity and diabetes examples of the “harmful effects” that were predicted? It does look that way. But at this point, at least one thing is clear: in the face of the deteriorating health of Americans and significant scientific evidence to the contrary, the USDA and HHS have continued to doggedly pursue a course of dietary recommendations that no reasonable assessment would determine to be effective.

But what does this have to do with race?

Maintaining the myth that a one-size diet approach works for everyone is fine if that one-size works for you—socially, financially, and in terms of health outcomes. The single positive health outcome associated with the Dietary Guidelines has been a decrease in heart attacks—but only for white people.

And if that one-size diet doesn’t fit in terms of health, if you end up with one of the other numerous adverse health effects that has increased in the past 35 years, if you’re a member of the mostly-white, well-educated, middle/upper-middle class demographic—you know, the one represented in the datasets that we continue to use as the backbone for our nutrition policy—you are likely to have the financial and social resources to eat differently from the Guideline recommendations should you choose to do so, to exercise as much as you need to, and to demand excellent healthcare if you get sick anyway. Even if you accept that these foods are Guidelines-recommended “healthy” foods, you are not stuck with the commodity crop-based processed foods for which our nutrition programs have become a convenient dumping ground.

In the meantime, low-income women, children, and minorities and older adults with limited incomes—you know, the exact population not represented in those datasets—remain the primary recipients of federal nutrition programs. Black, Hispanic, and American Indian kids are more likely to qualify for free or reduced-price school lunches; non-white participants make up 68% of the Special Supplemental Nutrition Program for Women, Infants, and Children enrollment. These groups have many fewer social, financial, and dietary options. If the food they’re given doesn’t lead to good health—and there is evidence that it does not—what other choices do they have?

When it comes to health outcomes in minorities and low-income populations, the “healthier” you eat, the less likely you are to actually be healthy. Among low-income children, “healthy eaters” were more likely to be obese than “less-healthy eaters,” despite similar amounts of sedentary screen time. Among low-income adults, “healthy eaters” were more likely to have health insurance, watch less television, and to not smoke. Yet the “healthy eaters” had the same rates of obesity as the “less-healthy heaters” and increased rates of diabetes, even after adjustment for age.

These associations don’t necessarily indicate a cause-effect relationship between healthy eating and health problems. But there are other indications that being a “healthy eater” according to US Dietary Guidelines does not result in good health. Despite adherence to “healthy eating patterns” as determined by the USDA Food Pyramid, African American children remain at higher risk for development of diabetes and prediabetic conditions, and African American adults gain weight at a faster pace than their Caucasian counterparts [7,8].

Adjusted 20-year mean weight change according to low or high Diet Quality Index (DQI) scores [8]

In this landmark study by Zamora et al, “healthy eaters” (with a high DQI) were compared to “less-healthy eaters” (with a low DQI). Everyone (age 18-30 at baseline) gained weight over time; the slowest gainers—white participants who were “healthy eaters”—still gained a pound a year. More importantly however, for blacks, being a “healthy eater” according to our current high-carbohydrate, low-fat recommendations actually resulted in more weight gain over time than being a “less healthy eater,” an outcome predicted by known differences in carbohydrate metabolism between blacks and whites [9].

Clearly, we need to expand our knowledge of how food and nutrients interact with different genetic backgrounds by specifically studying particular racial and ethnic subpopulations. Social equality does not negate small but significant differences in biology. But it won’t matter how much diversity we build into our study populations if the conclusions arrived at through science are discarded in favor of maintaining public health nutrition messages created when most human beings studied were of the adult, mostly white, mostly male variety.

Right now the racial demographics of the participants in an experimental trial or an observational study dataset doesn’t matter, and the reason it doesn’t is because the science doesn’t matter. What really matters? Maintaining a consistent public health nutrition message—regardless of its affect on the health of the population—that means never having to say you’re sorry for 35 years of failed nutritional guidance.

*ARIC – Atherosclerosis Risk In Communities (1987), 73% white; MESA – Multi Ethnic Study of Atherosclerosis (2000), 38% white, 28% African American, 12% Chinese, 22% Hispanic; CARDIA – Coronary Artery Risk Development in Young Adults (1985), 50% black, 50% white; SHS – Strong Heart Study (1988), 100% Native American; BWHS – Black Women’s Health Study(1995), 100% black women.

References:

1. Lee S, Harnack L, Jacobs DR Jr, Steffen LM, Luepker RV, Arnett DK. Trends in diet quality for coronary heart disease prevention between 1980-1982 and 2000-2002: The Minnesota Heart Survey. J Am Diet Assoc. 2007 Feb;107(2):213-22.

2. Hu FB, Stampfer MJ, Manson JE, Grodstein F, Colditz GA, Speizer FE, Willett WC. Trends in the incidence of coronary heart disease and changes in diet and lifestyle in women. N Engl J Med. 2000 Aug 24;343(8):530-7.

3. Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med. 2008 Apr 14;168(7):713-20. Erratum in: Arch Intern Med. 2008 Jun 23;168(12):1276.

4. Briefel RR, Johnson CL. Annu Rev Nutr. 2004;24:401-31. Secular trends in dietary intake in the United States.

5. Broad, WJ. NIH Deals Gingerly with Diet-Disease Link. Science, New Series, Vol. 204, No. 4398 (Jun. 15, 1979), pp. 1175-1178.

6. American Medical Association. Dietary goals for the United States: statement of The American Medical Association to the Select Committee on Nutrition and Human Needs, United States Senate. R I Med J. 1977 Dec;60(12):576-81.

7. Lindquist CH, Gower BA, Goran MI Role of dietary factors in ethnic differences in early risk of cardiovascular disease and type 2 diabetes. Am J Clin Nutr. 2000 Mar; 71(3):725-32.

8. 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.

9. Hite AH, Berkowitz VG, Berkowitz K. Low-carbohydrate diet review: shifting the paradigm. Nutr Clin Pract. 2011 Jun;26(3):300-8. Review.

RD does NOT stand for “Really Dumb”

All you need to do is google “dietitians are stupid.” (Go ahead, I’ll wait here.) “Dumbshit nutritionists” [Free the Animal] all over America are apparently giving out “misleading, scientifically vapid, and possibly harmful information” [Postpartum Punk]. Sadly, it is sometimes hard to argue with that.

The Academy of Nutrition and Dietetics has a professional “Code of Ethics” that states that all Registered Dietitians should avoid even the appearance of a conflict of interest.

“The dietetics practitioner does not invite, accept, or offer gifts, monetary incentives, or other considerations that affect or reasonably give an appearance of affecting his/her professional judgment.” *

At the same time, because the organization officially has exactly zero written standards for ensuring that its sponsors actually share the AND’s ostensible vision for “optimizing the nation’s health through food and nutrition,” the Academy of Nutrition and Dietetics accepts money from both food manufacturers and pharmaceutical companies and provides continuing education credits for attending workshops sponsored by Kellogg’s, Kraft and ConAgra.

So what might the Academy of Nutrition and Dietetics be doing with all of this funding? Right now, the AND is fighting a (mostly losing, thankfully) battle to create a complete monopoly on nutrition information and guidance—despite the fact that there is little evidence that this guidance contributes to positive health outcomes.

One the one hand, dietitians are encouraged to turn in anyone who does not rigidly adhere to both licensing standards and/or “professional” standards (some states have turned this into a professional development activity).  Anyone who gives out nutrition information without having the appropriate state-required licensing can be a target (Steve Cooksey’s story has been a newsworthy example of this). But—here’s the scary part—even dietitians with the right credentials can come under attack if they follow their professional judgement rather than the party line (see Annette Presley, below).

On the other hand, the “party line” approaches for weight loss are so ineffective, the federal government (and many states) won’t cover  many dietitian services to help people lose weight.    According to Dr. Wendy Long, chief medical officer of TennCare:

There’s really no evidence to support the fact that providing those services [from dietitians] would result in a decrease in medical cost, certainly not immediately, and even in the longer term.” 

This lack of evidence may be due in part to the (sadly) limited scope of dietetic education and practice. The AND treats the USDA as if it is a scientific authority and not a government agency whose first mandate is to “strengthen the American agricultural economy.” It limits the training of RDs to USDA/HHS-approved diet recommendations despite the fact that even mainstream nutrition establishment scientists feel that the current US dietary recommendations are misguided and inappropriate.

Despite these snugly-fitted, professional handcuffs, there are plenty of RDs out there who not only think for themselves, but who are working to change the system—each in her own way. What they have in common is an unwavering belief in the importance of food in creating healthier individuals and communities. Truly, these women are amazing:

Valerie Berkowitz MS RD CDN CDE worked with Dr. Robert Atkins for a number of years, but has gone one to create her own approach to healthy eating. Valerie is the author of The Stubborn Fat Fix: The Essential Guide to High Fiber, Low Carbohydrate, Whole Food Diets. The book is the basis for a learning module for continuing education credits for RDs—yup, you read that right. Thanks to Valerie’s commitment to making carbohydrate-reduction a mainstream option for health professionals, RDs can get continuing education credits for learning more about low-carb diets. More evidence of her commitment? I got to know Valerie well when I worked with her on a review paper on low-carbohydrate diets —while she had a newborn in tow. (All I did when my children were infants was pray for the opportunity to take a shower.)  Valerie works with her husband, Dr. Keith Berkowitz, as the Director of Nutrition at the Center for Balanced Health, while blogging, writing, and mothering four active children. I know, I know—it makes me want to take a nap just reading about her. But I promise she is fully human and a lovely person. Go visit her at Valerie’s Voice: For the Health of It.

Abby Bloch PhD RD is the Executive Director for Programs and Research at the Dr. Robert C. and Veronica Atkins Foundation. Like Jackie Eberstein, she also has a story about being interviewed by Dr. Atkins and telling him that if she found out that he was a fraud, she would shout it from the rooftops. Well, he wasn’t and she didn’t, and she’s been working with the Atkins Foundation ever since. She is an RD who, quite literally, wrote the book on feeding cancer patients. When she began her career, doctors didn’t think trying to meet the nutritional requirements of cancer patients was all that important: if they lived, they’d eat again eventually; if they didn’t, oh well. Abby’s book paved the way to the now commonplace understanding that appropriate nutrition could make the difference between the first outcome and the second.

Allison Boomer MPH RD is a food writer who brings her nutrition expertise and love for food together in her work for The Boston Globe and other media outlets. I met Allison when she was working on a piece in about fat and the Dietary Guidelines. It hasn’t always been easy for her to educate the public about the complex realities of how science and policy don’t always match up—she makes her editors rather nervous—but she understands the importance of conveying this information in a readable and entertaining manner. As we see the low-fat tide turning, it is due, at least in part, to efforts like hers.

Cassandra Forsythe PhD RD has worked with low-carb researcher Dr. Jeff Volek, but that doesn’t even begin to describe the breadth of her expertise. She combines a background in dietetics, nutrition, and exercise science with a particular interest in women’s health—especially mommy health. If you happen to be a reader with more of a passion for working out than I have (which is likely to be every reader) or if you are not interested in joining the “fat mother’s club” (as my brother so charmingly described the tendency of bearing children to leave women looking permanently 5 months pregnant), check out her fun/exhausting combination of “cute baby and badass mommy” blog.

Suzanne Hobbs PhD RD comes from a different nutrition perspective than many of the women on my list, but she is—quite literally—the only person in America whose area of expertise encompasses both nutrition care and nutrition policy and politics. She is a lifelong vegetarian who writes a newspaper column highlighting the nutrition benefits of a plant-based diet. But she is no more of a vegetarian hard-liner than I am a low-carb one. Instead, she understands that the food choices that people make are complicated, the environment in which those choices are made is confusing, and the real target of concern—for any nutritional paradigm—should be how to take this big messy picture and frame it in a way that will allow us to improve public health nutrition for everyone, rather than to promote any one nutrition agenda. She helped put vegetarian nutrition on the map in the world of dietitians as well as the world of policy. I’m hoping I can learn from her how to stretch the old “top-down” model of nutrition guidance into a new shape that allows us to start thinking differently about how to accommodate individualized nutrition to a public health framework.

Amanda Holliday MS RD LDN is a mother, wife, daughter, and granddaughter—who never relinquishes the importance of those roles as she juggles multiple professional demands as the Director of the University of North Carolina at Chapel Hill’s Registered Dietitian/Masters of Public Health Program, clinician, instructor, public health leader, and blogger. Her family relationships inspired her specialization in nutrition for older adults, another booming subpopulation of Americans for whom standard one-size-fits-all dietary recommendations are inappropriate. Both fearless and humble, she has more integrity in her pinkie toe than most public health advocates could hope to accumulate in their lives. I think she simply lacks the ability to tolerate hypocrisy. She has a deep appreciation for the power of science to improve patient care; she always insisted that her RD students hold themselves to much higher standards of scientific knowledge and expertise than is actually required for dietitians. She also has a healthy respect for the flaws and limitations of science in addressing the complicated needs of real individuals. She never lets her students forget that they are treating people, not symptoms.

Karen Holtmeier MPH RD LN is the RD counterpart to Mary Vernon’s MD leadership at the American Society for Bariatric Physicians as well as director of her own weight loss clinic. She has been educating dietitians and nurses that work with bariatric physicians about the positive health effects of carbohydrate reduction for over a decade, while remaining active within the RD professional community. Not an easy feat to pull off, but Karen is not only warm, funny, and politically savvy, she’s one of the most intrepid women I know. (Traveling by myself still is a little nerve-wracking–with a husband and three kids, I’m used to traveling in a mangy but secure pack loaded down with coolers, pillows, and a bookmobile’s worth of reading material; Karen thinks nothing of hopping in the car for an extended road trip, by herself, up the US west coast and into Canada—tralala. I love that.)

Kris Johnson RD (retired) is one of those “mystery women” I’d run into all over the internets. Like Carmen Sandiego, everywhere I’d go, she seems to have gotten there first. Outraged and intelligent commentary on the attempts of the Academy of Nutrition and Dietetics to create a monopoly on nutrition guidance?

As a retired and reformed dietitian, I can say flat out, dietitians do not understand all there is to know about nutrition. In fact conventional RD’s persist in promulgating some very bad science, such as the misguided advice to avoid saturated fat and cholesterol and aim for a low fat diet. Much of the really useful nutrition information I learned after I retired.

A science-based view of saturated fat in response to outdated precautionary warnings?

Those who have looked carefully at the research have found no evidence that natural saturated fats or cholesterol actually cause heart disease or any other health problem. . . . Excessive amounts of polyunsaturated fats and the trans fats derived from them are the real problem. The best way to improve important cardiac risk factors, that is increase HDL and lower triglycerides, is to limit carbs and most vegetable oils, while getting adequate natural saturated fats in the diet.

I think one of the coolest things about Kris is that she worked as an RD for 15 years, retired, and—instead of spending all day playing Suduko—then she went on to read and learn enough about the shifting paradigm in nutrition to become a vocal and articulate advocate for change. Amazing. Check her out at www.MercyViewMedow.org.

Amy Kubal MS RD LN is another dietitian who combines her expertise in nutrition with a love for athletics. As part of Robb Wolf’s team, she gives the “mainstream” RD designation a paleo twist. Her ability to bridge both worlds is a welcome sign of the times.

Stacia Nordin RD combines her nutrition expertise with permaculture knowledge and the desire to end hunger in Malawi, Africa in a socially, environmentally, and nutritionally sustainable way. Never Ending Food is a family endeavor she shares with her husband and her daughter (who was born in Malawi). I met her after getting a post about the AND’s campaign to create a monopoly on nutrition guidance yanked from an RD discussion board. Her response was sympathetic and encouraging, and she introduced me to a number of other RDs whose agreed with my position, but who had much better diplomacy skills than I do! (One day, we would like to create a network of nutrition professionals with an array of credentials—RD, CNS, CCN, CNC, health coach—to work together to create an environment where all of us can practice our profession with mutual respect.) In the meantime, Stacia and her family’s work continues to inspire me to think about how to make sure that our food reform efforts begin with the communities that they are intended to serve.

Annette Hunsberger Presley RD, co-author of The Liberation Diet, was censured by the (then) American Dietetic Association for recommending that her clients use butter instead of margarine. When told to review the ADA’s Evidence Analysis Library (whose idea of “evidence” is so limited and biased that I have a hard time typing the phrase with straight face) to get the “facts” straight and renounce this position, she did. Plus, she reviewed the rest of the science on the subject and reached a conclusion—as you may have guessed—with which the ADA was not at all happy. You can read her Hyperlipidemia Report here; it’s a pretty amazing piece of work.

Pam Schoenfeld RD is not only a wife, mother, clinician, and public health advocate, she is also the person I blame for getting me into this mess! Together we started Healthy Nation Coalition, and it’s been quite an adventure.I still have the email she sent Dr. Eric Westman (the MD I worked with at the Duke Lifestyle Clinic), and which he passed on to me, describing some of her experiences as an RD intern. Her passion, concern, and professional assessment of nutrition science were inspiring and contagious. She convinced me that I wasn’t too old to go back to school and that I’d come through the dietetic groupthink hazing intact. She was—more or less—right. She remains my hero, mentor, and dear friend.

Picture Franziska Spritzler RD CDE is applying her nutrition expertise to specifically help patients with diabetes (CDE stands for Certified Diabetes Educator).  As Type 2 diabetes has reached epidemic proportions in this country and across the globe, we seem to have forgotten that it is designated in the prominent physician’s handbook, The Merck Manual, as a “disorder of carbohydrate metabolism,” and that, prior to the widespread use of insulin, Type 2 diabetes was effectively treated with a carbohydrate-restricted diet.   As The Low-Carb Dietitian, Franziska is reviving this wisdom in her own practice and for the benefit of everyone struggling with diabetes.

Joanne Slavin PhD RD was a member of the 2010 Dietary Guidelines Advisory Committee. I started following her through the transcripts of those meetings. What caught my attention was her commitment to 3 things: science, food, and people.  She’s been slagged on in the paleo community for being—gasp—a realist about both food prices and the fact that grains can be a perfectly reasonable source of calories for some people—like the teenage male who lives at my house—who actually need calories and can tolerate-grains-just-fine-thank-you. [Labeling her a “dumbshit nutritionist” is—imho—part of why paleo has good reason to be worried about its own future as a fringe-y food and fitness fad. In the brave new world of nutrition, we have to feed everybody, not just the people who agree with that ideology.]

Here’s our “dumbshit nutritionist” speaking to the Registered Dietitians assembled at the North Carolina Dietetics Association conference in April 2012.  Fangirl that I am, I literally tried to write down everything she said:

“The 1977 Dietary Goals were based on politics, not science.”

“Humans can adapt to a wide variety of diets—from 80% carbs to 80% fat.”

“Increasing intake of plant foods, which are low sources of protein, is a bad idea for growing children.”

“People who eat more carbohydrates weigh less, so eat more carbohydrates. Um, it doesn’t work like that.”

“A lot of people don’t get enough protein because of what they are choosing.”

“Dietary advice often has unintended consequences.”

“Micromanaging the diet by imposing strict dietary rules is difficult to support with evidence-based nutrition science.”

“Pink slime was created to come up with a low-fat, high-protein thing to put into processed food.”

“I believe fat needs to go higher and carbs need to go down.”

“It is overall carbohydrate, not just sugar. Just to take sugar out is not going to have any impact on public health.”

Dr. Slavin is NOT a low-carb or paleo diet advocate; she is simply reporting on the realities of nutrition science and policy. But if you have any lingering concerns about her being a “lackey” for the USDA and food industry, here she neatly and sweetly skewers the whole paradigm:

The 2010 Dietary Guidelines for Americans supports less consumption of sodium, solid fats, and added sugars. Make half your grains whole and half your plate fruits and vegetables. Seems simple for the food industry—keep slashing salt (but make sure my food is safe), get rid of added sugar (but add fruit and fruit extracts to everything), and make chips, pizza crust, cookies, and all other grains “whole” so they are healthy. Probably a good idea to tax soda, outlaw French fries, ban chocolate milk in schools (added sugar is bad, right?), and over-regulate school lunch, restaurants, and food manufacturers. Let’s blame the victim too—we know fat people are lazy, uneducated, and low income—too bad they live in food deserts and don’t have access to fresh fruits and vegetables. Hope my BMI is under 25 today!

Dr. Slavin is a mainstream nutrition expert and RD.  She is also an independent thinker and a true scientist.  The paleo community’s stance in making nutritionists like Dr. Slavin out to be the “enemy” is not only short-sighted and counterproductive, it’s inaccurate.   People like her will pave the way for better public health nutrition for everyone–including those who choose paleo diets.

This list would not be complete without a shout-out to all the dietitians I’ve met at the newly-formed PaleoRD group started by Aglaee Jacob MS RD—who deserves her own hooray (Aglaee, Your Paleo RD! It rhymes and everything!). I hope that the existence of such a group—you don’t have to be “paleo” to join—will encourage other RDs to stand up for their own professional understanding of the science and not feel afraid of being censured. There is strength in joining our voices together.

I’d love to hear about other RDs who share the belief—to paraphrase Kris Johnson—that the Academy of Nutrition and Dietetics doesn’t know all there is to know about nutrition and the conviction that as dietitians and nutritionists, we can and should exercise our professional expertise and judgment to help heal the world through food.

* From:
American Dietetic Association. American Dietetic Association/Commission on Dietetic Registration code of ethics for the profession of dietetics and process for consideration of ethics issues. J Am Diet Assoc. 2009 Aug;109(8):1461-7.

Where the Women Are, Nutrition Edition

I really try not to pout too much when I see lists like the one below from Jimmy Moore’s 2012 survey on “most trusted resources for the information you received about health”:

After pouring through a couple hundred names that people shared, here were the top 10 who made the list in 2012:

1. Mark Sisson (30%)
2. Robb Wolf (23%)
3. Gary Taubes (21%)
4. Chris Kresser (15%)
5. Sean Croxton (10%)
6. Dr. Mike Eades (9%)
7. Dr. Robert Atkins/Atkins.com (8%%)
8. Dr. William Davis (7%)
9. Tom Naughton (7%)
10. Diane Sanfilippo (6%)

But seriously?  ONE woman?  ONE?  That’s it?????? Good grief.

The reasons for this imbalance are another blog post.  Instead, I chose to channel my energies into introducing some women who are leading the way—in their own way—in the world of nutrition.  If there appears to be a  “bias” in that most of these women–in one way or another–suggest that the current “grains are great” approach to nutrition is an unsound approach to good health, you might ask yourself how much that has to do with the prevailing bias within our current, and highly unsuccessful, nutrition paradigm.  These women are leaders, not followers.

To me, they are the Chers, Madonnas  and Dolly Partons of the nutrition world, although with a few exceptions, you may not recognize their names (which I know is part of the problem). Most have them have been around the block a time or two, and they know how the game is played—and rigged. They’ve succeed by being entirely who they are—tough-minded broads, compassionate caretakers, and reluctant warriors in the cause for good health for all.

Some of these women I’ve met, some I know well, some I’ve only admired from a safe distance afar. I wouldn’t expect all of these women to agree with—or even like—each other, or me, for that matter. Some of them may be appalled to find themselves on this list at all. Oh well. I don’t agree with all that each of them has to say, but I embrace the diversity and the chance to recognize some women I think have shown us how to have the huevos we need for the work ahead of us.

So—without further ado, and in alphabetical order (why not?)—here they are.

Judy Barnes Baker brought us this useful meme.

Judy Barnes Baker came this close to getting the American Diabetes Association to publish and endorse her reduced-carb cookbook. When that arrangement fell through, she got her cookbook published anyway and went on to publish another. Like Dana Carpender (see below), she’s been making life easier for those folks who want a low-carb approach to life.

Dana Carpender is a force of nature. She’s been holding the toast since 1996, and with her technogeek husband, Eric, has been able to bring us that message over the web since the dawn of the internet. Her book and cookbooks have been a lifeline for many trying to figure out exactly how to put into practice a way of eating that makes them feel healthy and happy. And boy, does she ever have a mouth on her. Sometimes I think it would be fun to lock her in a padded room with Frank Sacks and see who makes it out intact. I know where my money would be.

Laurie Cagnassola

Laurie Cagnassola, dog-lover extrodinaire, was, until recently, the Director of Nutrition and Metabolism Society, a leading low-carb oriented organization. She managed to gracefully meld the work she did with NMS with her own stance as a vegetarian. While Richard Feinman lambasted the entrenched interests in science and government out front, she worked tirelessly behind the scenes to build the fledgling reduced-carbohydrate nutrition community into a full-grown movement.  I expect we’ll hear more from her in the future.

Laura Dolson’s beautiful Low-Carb Pyramid

Laura Dolson has been writing about the food, science, and politics of low-carb nutrition for over a decade.  As a person who “walks the walk,” her posts on about.com are an informative and realistic guide to carbohydrate reduction.

Mary Dan Eades MD is the beautiful half (okay, the beautiful half on the right, for all you women out there drooling over her husband) of the royal (protein) power-couple of the carb-reduction world, Drs. Mike and Mary Dan Eades. They are the authors of multiple diet and lifestyle books beginning with Protein Power, which helped me navigate my own personal path to health many years ago. She may prefer to focus on singing, traveling, and grandkids now, but her voice is what gave the brilliant biochem wonkiness of Protein Power its warmth, humanity, and accessibility.

Jackie Eberstein RN was Dr. Robert Atkins right-hand RN for many years. She’s soft-spoken, with a backbone of steel and a heart of gold. She thought Atkins was “a quack” when she interviewed for the job. Thirty years later, she was still marveling at the improvement people could make in their health following his diet. But she’s no extremist. She taught me the importance of making sure calorie levels on a low-carb diet were appropriate. She’s got her hands full with her husband, Conrad, a charmer who can seriously rock a bow tie.

Mary G. Enig PhD is co-founder with Sally Fallon Morrell of the Weston A. Price foundation. Her work on fats led her to be one of the first voices raised in warning about the dangers of trans fats—and she’s been battling the seed oil industries attempts to silence and marginalize her work ever since.

Mary Gannon PhD, has—along with her research partner, Frank Nuttall—been working quietly on the low-biologically-available-glucose (inelegantly known as the LoBAG) diet for a decade now, although her work stretches back into the 70s. She is persistent in her efforts to understand the benefits of reduced carbohydrate and increased protein in helping to reverse the symptoms of type 2 diabetes.

Zoe Harcombe has been researching obesity for a couple of decades now. A UK writer, researcher, and nutritionist, her book, The Obesity Epidemic, is giving readers on the other side of the pond a different perspective on nutrition.

hartke is online podcast

Kimberly Hartke puts the “life” in lifestyle changes as the publicist for the Weston A Price Foundation. She’s collected enough stories from being on the front lines of the nutrition revolution to write a book, which I am truly hoping she will do one day soon.

Weigh loss success story

Misty Humphrey’s warmth and humor permeate her writing and advice on diet and health.   If there was ever a way to screw up getting healthy Misty’s done it and she’s honest and funny as she tells her story and helps her readers avoid the same pitfalls.

Lierre Keith’s Vegetarian Myth is not just another story of someone who found that their favored way of eating didn’t work and—prestochango—transformed themselves and their health by discovering The Truth About Food. The power of her book lies in her examination of the beautiful myth that underlies vegetarian thinking—that we can somehow peacefully eat our way to personal and global health without any regard for ourselves as critters who—just like all other critters—must function within an ecosystem that is nothing but one expression of eat/be eaten after another. I like to put her book on the shelf next to Jonathan Safran Foer’s goofball Eating Animals, which amounts to little more than a literary snuggie for vegans (JSF considers the American Dietetic Association the very last word in science-based nutrition information <guffaw>). I expect The Vegetarian Myth to simply drain the ink off the pages of Eating Animals out of sheer proximity.

CarbSane’s Evelyn Kocur, shows us–and the rest of the world–what the focused energy of one cranky woman who thinks we’ve been fed a load of crap looks like. Although I’m not a fan of her style—after years of listening to my mother scream, even reading someone else’s raging makes me want to hide under the bed—I can nevertheless admire the no-holds-barred way she skips the warm fuzzies and goes straight for the jugular. I really wish–every now and then–that I could pull that off.  Even when she’s missed the target by a mile, I have to give her credit for sheer firepower.

Sally Fallon Morrell is the director and co-founder (along with Dr. Mary Enig) of the Weston A. Price Foundation. Sally Fallon Morrell is a mother of four and a force of nature who doesn’t mince words. She’s ticked off at least one person in the paleo movement with regard to her stance on saturated fat, but—as far as I can tell—he’s ended up changing his position on the subject; she hasn’t changed hers.

Patty Siri-Tarino, PhD, is lead author of the meta-analysis on the lack of association between saturated fat and heart disease that changed the nature of conversation about nutrition and prevention of chronic disease.

No pink fluffy weights for Krista Scott-Dixon

Krista Scott-Dixon is the first person I found on the internet who said lifting big heavy things is for women too. She taught me—and countless numbers of other women–how to squat and that feminist theory and nutrition do so go together. And she makes fart jokes. You could really just not bother reading anything else I write and just read her stuff. Case in point: a free e-book entitled, Fuck Calories. (As Krista says: Yes, this book has cuss words. Many of them. Deal with it. Hey, it’s free. You get what the fuck you pay for.) Could she get any cooler? She’s married to a rocket scientist.

Mary Vernon MD has been at the forefront of reduced-carbohydrate nutrition for many years as a leader at the American Society of Bariatric Physicians. This group has partnered with the Nutrition and Metabolism Society to encourage conversation within the scientific/academic/clinical setting about reduced-carbohydrate nutrition: its pros and cons; the science behind it; and its clinical application. When national nutrition policy eventually catches on, it will be due in no small part to the fact that Mary Vernon and ASBP have already been offering this nutrition option to patients for years.

Regina Wilshire is the inspiration for a folder on my desktop entitled, Regina Brilliance. She is full of common sense and uncommon smarts. Wife, mother, and tireless blogger, her Weight of the Evidence (now on facebook too) has been a resource for intelligent and insightful commentary on nutrition since 2005. In the midst of the PubMed duels we so often find ourselves wrapped up in, her posts on eating well on a food stamp budget bring a welcome reality check.

Daisy Zamora PhD fought battle after battle (a story she’s agreed to let me tell one day) to publish her groundbreaking research on why our one-size-fits-all diet may be especially devastating to the health of minorities. It is not difficult to imagine why the powers-that-be would not want this indictment of the failure of our dietary recommendations to be made public. But beyond being a quiet crusader for rethinking our current dietary paradigm, she recognizes the importance and centrality of food in our lives and health. You have no idea how rare it is in the world of academic nutrition experts to find someone who eats and cooks and talks about food—as opposed to nutrients in food—and, get this, appears to actually like the stuff!

Let me know who’s on your list, or who I should add.

Plus, if that’s not enough, I found that, in putting together this list, many of the women I admire in the field of nutrition are–gasp–Registered Dietitians. Since RDs catch so much crap from the rest of the alternative nutrition community about being mindless-Academy-of-Nutrition-and-Dietetics-robots, I thought I’d put together a list of RDs who have inspired me to continue to work towards better health for all, despite our own professional organization’s insistence on using USDA/HHS policy as if it is science and its wince-inducing reliance on both food and pharma funding.

Next up: Where the Women Are, RD edition.

The REAL Paleo Challenge: How NOT to be Just Another Elitist Fad for Skinny White People Wearing Goofy Shoes

The blogsphere is beginning to rattle with commentary on the recent Ancestral Health Symposium 2012 events. Some folks who don’t necessarily “look the paleo part” have voiced concern about feeling excluded or marginalized as the conversation/social activities/celebrity parade seemed dominated by:

  • white people
  • young people
  • thin/athletic/fit people
  • men
  • well-educated, upper-middle class socioeconomic status people
  • people wearing goofy-looking shoes

You can read my take on why that might be the case here: AHS 2012 and the BIG BUTT: Lessons in Nutritional Literacy.

I understand that an NPR reporter was at the event, interviewing some of the movers and shakers. There was some concern that the reporter seemed to think that the paleo movement is a bit of an elitist fad. I understand this perspective, and on many levels, I agree.

As a “fad,” the paleo movement is a bunch of highly enthusiastic people with a lot of disposable income and time who are deeply committed to a particular way of being fit and healthy. It has its leaders, it controversies, its “passwords” (can you say “coconut oil” or “adrenal burnout”?), and its stereotypical paleo dude or dudette. As a fad, it would be destined to go the way of all of other diet and health fads—including Ornish and Atkins, Pritikin and Scarsdale, extending all the way back to the “Physical Culture” movement of the earlier part of this century (Hamilton Stapell spoke about this at AHS2012).

The original paleo chick – no high heels on this lady

Is it elitist? Well, there are some ways that it is possible that the paleo movement may marginalize the very folks who might benefit most from its efforts. Maybe an African-American guy still sensitive to the fact that his grandfather was consider “primitive” might not want to get his full cavemen on. Maybe a Mexican-American woman who remembers her abuela telling her stories about being too poor to have shoes doesn’t really want to go back to being barefoot just yet. Maybe an older, heavier person simply feels intimidated by all the young healthy fit people swarming to the front of the food line.

But the paleo movement does not have to be an elitist fad unless insists on limiting itself to its current form, and I believe the people at the Ancestral Health Society  are working hard to make sure that doesn’t happen. This is why I really love these folks. I don’t mean the paleo leaders like Mark Sisson or Robb Wolf, although I’m sure they’re good people; I’ve just only met them briefly. I mean those somewhat geeky-looking-in-an-adorable-sort-of-way folks in the brown T-shirts who hung in the background and made it all happen for us last week. Notice that they don’t call themselves the Paleo Health Society, right? I love them because they ask good questions, they question themselves, they think long-term, and they’ve created a community that allows these conversations to take place.

So, what do we do to transform this paleo-led, AHS-supported community into the public health, human rights revolution it could be?

According to Doug Imig at the University of Memphis, a protest becomes a movement when:

1) It defines and proclaims widely shared cultural norms.

2) It creates dense social networks.

3) It gives everybody something to do.

Each of these deserves its own blog post, so let’s look at the first—and most important—item: widely shared cultural norms. This is where the “elitist fad” part of paleo falls short, but not really. Because in all my encounters with paleo folks and people from AHS, I find norms and values that the culture as a whole can embrace. Here’s the weird thing, I’ve spend the past couple of years also talking to mainstream scientists, from one end of the diet spectrum to another, including Joanne Slavin, a down-to-earth, warm, wonderful lady who was on the most recent Dietary Guidelines Advisory Committee and Henry Blackburn, who is a delightful gentleman and a protégé of Ancel Keys. Guess what? We all have some values in common.

Here are some concepts that I think may unite us all, from vegan to primal, from slow food to open government, from “mainstream” scientist to “fringe scientists” like Gary Taubes (yes, one of my UNC instructors referred to GT as a “fringe scientist,” although another found his views “very convincing”—go figure):

We must create an open, transparent, and sustainable food-health system.

The RD that inspired me to take an internship at the American Dietetic Association for a semester, Mary Pat Raimondi, said: “We need a food system to match our health system.” And whatever shape either of those systems may take, she is absolutely right. Conversations about food must encompass health; conversations about health must encompass food.

Right now our food-health system is closed. Directives come from the top down, public participation is limited to commentary. The people who are most affected by our nutrition policies are the farthest removed from their creation. We need to change that.

Right now our food-health system lacks transparency. USDA and HHS create nutrition policy behind doors that only seem to be transparent. Healthy Nation Coalition spent a year filing Freedom of Information Acts in order to get the USDA to reveal the name of a previously-anonymous “Independent Scientific Panel” whose task, at least as it was recognized in the Acknowledgments of the Dietary Guidelines, was to peer-review “the recommendations of the document to ensure they were based on a preponderance of scientific evidence.” You can read more about this here, but the reality is that this panel appears to not be a number of the things it is said to be. This is not their fault (i.e. the members of the panel), but an artifact of a system that has no checks and balances, no system of evaluation, and answers to no outside standards of process or product. This must change.

Our food-health system must be sustainable. And Pete Ballerstedt would say, yes, Adele, but what do you mean by “sustainable”? And to that I say—I mean it all:

Environmental sustainability – Nobody wants dead zones in the Gulf or hog lagoons poisoning the air. But environmental sustainability can’t be approached from the perspective of just one nutritional paradigm, because a food-health system must also have:

Cultural sustainability – We are not all going to become vegans or paleo eaters. Our food-health system must support a diversity of dietary approaches in ways that meet other criteria of sustainability.

Economic sustainability – Our food-health system must recognize the realities of both producers and consumers and address the economic engines that make our food-health system go around.

Political and scientific sustainability – Our food-health system must become a policy dialogue and a scientific dialogue. Think of how civil rights evolved: an equal rights law was passed, then overturned, a Jim Crow law was passed, then overturned, an equal right law was passed, then upheld, etc. etc. This dialogue reflected changing social norms and resistance to those changes. But we have no way to have a similar sort dialogue in our food-health system.

What would the world look like if, in 1980, an imaginary Department of Technology was given oversight of the development of all knowledge and production associated with technology? Production of food and knowledge about food (i.e. nutrition) became centralized within the USDA/HHS in 1977-1980 and there have been no policy levers built into the system to continue the conversation, as it were, since then. The Dietary Guidelines have remained virtually unchanged since 1977; our underlying assumptions about nutrition science have remained virtually unchanged since 1977. That’s like being stuck in the age of microwaves the size of Volkswagens, mainframe computers with punchcards, and “Pong.” We need a way for our food-health system to reflect changing social and scientific norms.

One of the primary shifts in understanding that has taken hold since 1977 is that:

There is no one-size-fits-all diet that works for everyone.

In 1979, Dr. William Weil Jr at the Department of Human Development at Michigan State University, voiced concern about “the frequent use of cross-national and cross-ethnic inferences” [Weil WB Jr. National dietary goals. Are they justified at this time? Am J Dis Child. 1979 Apr;133(4):368-70.]  He went on to day that we cannot assume that “because ‘a’ and ‘b’ are correlated in one population group that they will also be correlated in another group” yet our one-size-fits-all dietary recommendations make just that assumption.

There were more scientific articles generated from the Nurses’ Health Study–composed of 97% white women–in 2009 alone, than in the entire 10+ year history of the Black Women’s Health Study. Those large epidemiological studies done with a mostly white dataset are what drive our policy making, even though evidence also points to fact that we should not be making the assumptions to which Dr. Weil referred. 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 [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].

.

DQI stands for Diet Quality Index. Blacks with a higher DQI had more weight gain over time than blacks with a lower DQI. From Zamora et al.

Even with a more homogenous population, this issue applies. Remember all those discussions about “safe starches” you heard at AHS2012?

This concept also captures the emerging knowledge of how genetic variability affects nutrition needs and health, i.e. individualized nutrition, a very useful buzzword. I have lots to say about n of 1 nutrition coming up soon. But, most of all, not trying to cram everyone into the same nutritional paradigm captures reality of our own lives and choices about food. Which brings me to:

Food is not just about nutrition, and nutrition is not just about science.*

When we all begin to question our own assumptions about food and nutrition, we will be better able to reach across communities, create common ground, and be humble about our way forward.

We need to understand and help others understand that all nutrition messages are constructed and contain embedded values and points of view.

We need to learn to ask and teach others to ask: Who made the message and why? Who may benefit or be harmed? How might people interpret this message differently?

We need to think and help others to think about income and funding models, industry, and the framing of dietary problems by scientist, bloggers, and the media (and I don’t just mean “the other guys”—apply these critical thinking skills to your own nutrition/food community).

Nothing about our food and nutrition thinking was born in a vacuum. Food is a part of our cultural and social fabric. It allows us to belong; it allows us to define ourselves. Even as we strive to find better science and to shift our current diet-nutrition paradigm, we must approach this with the understanding that there is no truly objective science. How science gets used, especially in the policy arena moves us even farther from that non-existent ideal. Even as we strive to improve public health, we must understand that we don’t always know what “health” and “healthy food” means to the people we think we are trying to serve.

If these points sound remarkably like the mission statement for Healthy Nation Coalition, my non-profit, then you’ve been paying attention. But it is not my plan for HNC to “lead” any nutrition reform movement as much as it is for us to get behind everyone else and shove them in the same direction. There is very much a herding kittens aspect to this (as Jorge of VidaPaleo.com pointed out), but as a former high school teacher and mother of three, this is not new territory to me.

So, yes, I have an agenda. Everyone has an agenda. I’ll spell mine out for you:

Somewhere out there in America, today, there is a young African-American girl being born into a country where many—if not most—of the forces in her world will propel her towards a future where she will gain weight, get sick, have both of her legs amputated, get dialysis three times a week, be unemployed and unemployable, on disability and welfare, and—this is what gets me out of bed in the morning and drags my weary ass to one more round of getting punched in the face by those very forces arrayed against her—she will, somewhere underneath it all, blame herself for her situation. I’m an old white lady, in a position of relative power and knowledge. I don’t know this young lady, and she doesn’t know me. She doesn’t owe me anything because she’s not asking for my help. But it is my job in this life to begin—at the very least—to shift those forces so that she has a better opportunity to choose a different life if she wants to. That’s all I care about. I don’t care who gets credit or who gets the cushy book deal.  I just want it to happen.  I would want the world to do the same for my children if they had not had the privilege of birthright that they do. That child is my child as sure as the three that live here and drive me crazy are. All I ask of the paleo community is that she be your child too. And if, as a community, you decide to adopt this child, well then, don’t worry about becoming an elitist fad made up of goofy-shoe wearing white people destined to fade into obscurity. Instead, you all will change the world.

Next Up: What makes a movement? (and I mean a social change one, not the bowel-y kind)

*Much of what follows borrows liberally from the work of Charlotte Biltekoff at UC-Davis, a wonderfully warm and intelligent woman who has been working on and thinking about this issue for—believe it or not—longer than Gary Taubes. She has a book coming out next summer which, IMHO, will be the social/cultural partner to Good Calories, Bad Calories.

Calories in, Calories out, Would You Please Go Now!

Ah, calories! Let me count the ways . . . that calorie-counting is a limited, grossly over-simplified, and ultimately highly unproductive way of addressing weight or health.

According to some, the key to health and a healthy weight is making sure your calories in = calories out. This is called being “in energy balance,” and, according to the USDA 2010 Dietary Guidelines, this is what most Americans are “out of.” We are fat because we eat more calories than we need—whatever that means. And the only way to NOT be fat is to “eat less and move more.”

Sounds simple enough. So why doesn’t it seem to work all that well?

Let’s start with the basics:

  • When a person decreases their “energy in,” that person’s “energy out” also goes down. For example, take Ancel Keys’ early starvation experiments.

  • When a person increases their “energy out,” that person’s “energy in” goes up. For example, take my 6’7″ basketball- & soccer-playing nephew out for dinner.


[Shameless Auntie plug: check out his latest endeavor, “Kicking across Carolina]

Eating less and moving more is like breathing underwater: not impossible, but somewhat awkward and unnatural. Some turtles can breathe underwater through their butts; some people can eat less and move more. For a lot of us, we are as likely to be as successful at the former as we are at the latter.


Turtles can, can you?

What? you say. But it’s SO obvious. People who eat less, weigh less; how much simpler could it be?

Except that we don’t really have a lot of data that demonstrates that this is the case. Oddly enough, this is a cross-cultural, age-independent, apparently universal, problem.

For example, for these American Indians, higher BMI is associated with lower calorie intake.


From: Xu J, Eilat-Adar S, Loria C, et al. Dietary fat intake and risk of coronary heart disease: the Strong Heart Study. Am J Clin Nutr. 2006 Oct;84(4):894-902.

In this Mediterranean population, higher BMI is associated with lower calorie intake.


From: Casas-Agustench P, Bulló M, Ros E, Basora J, Salas-Salvadó J; Nureta-PREDIMED investigators. Cross-sectional association of nut intake with adiposity in a Mediterranean population. Nutr Metab Cardiovasc Dis. 2011 Jul;21(7):518-25. Epub 2010 Mar 9.

In these kids, higher BMI is associated with lower calorie intake.


From: Qureshi MM, Singer MR, Moore LL. A cross-sectional study of food group intake and C-reactive protein among children. Nutr Metab (Lond). 2009 Oct 12;6:40.

Yeah, in these kids too.


The trend continues as kids become teenagers. Strangely, the teens who move more, eat more; the teens who move less, eat less. And, surprise, higher BMI is associated with lower calorie intake. Hmmm.


From: Patrick K, Norman GJ, Calfas KJ, et al. Diet, physical activity, and sedentary behaviors as risk factors for overweight in adolescence. Arch Pediatr Adolesc Med. 2004 Apr;158(4):385-90.

As you may be aware, some researchers do have an explanation for this phenomenon: Fat people lie. That’s certainly a much more convenient explanation than examining the possibility that there is more to nutrition metabolism than “calories in, calories out.

Sadly, this lying stuff apparently starts young. In this study, the researchers concluded that the 9-year old girls under investigation are apparently lying about how much they eat:

“Importantly, this study found that the positive association between energy intake and adiposity was observed only after excluding implausible energy intake reports, but not in the total sample which included implausible reporters, the majority of which were overweight children who under-reported energy intake.”

This means there is no association between calories and overweight in the general sample. An association is only found if the researchers exclude “implausible” intakes of overweight children who “under-report” what they eat. The researchers determine which intake levels were “implausible” because they know how to calculate how much fat kids are supposed to be eating:

“Physiologically plausible reports of energy intake were determined by comparing reported energy intake with predicted energy requirements.”

In other words, if the chubby little girls don’t eat as much as the researchers think they should be eating, as calculated using formulas that are notoriously inaccurate, then the conclusion is that they (the girls, not the researchers) are lying.

Luckily, the folks at the USDA are totally on top of this issue and can give us a clear explanation of what is going on:

“One would expect to find a strong positive association between caloric intake and a measure of body fatness, such as the body mass index (BMI).”

Yes, one would, if one thought that all that really matters is how many calories go in and how many calories go out.

“However, nutrition studies using self-reported food intake data, such as the CSFII data, have failed to find such an association, . . . ”

Y’don’t say? Hmmm. Wonder why that could be? Maybe nutrition is more complicated than a simple energy balance equation?

” . . . primarily because overweight persons tend to underreport intakes to a greater degree than healthy weight persons.”

Oh right, I forgot. So, they’re all lying? Native Americans, people in other countries, old people, young kids (or maybe their parents)?

Also, at any given time, overweight persons may be on weight-loss diets. ” [emphasis mine]

Ohhh.  That might help explain things. In other words, fat people either do not have the moral fortitude to be honest with themselves or anyone else about how much they eat, or they are—bravely, in the face of ridiculous odd against them—reducing the number of calories they eat.

In a study examining the association between calorie intake and BMI in women who are dieting, the investigators found, big surprise, an inverse association between BMI and calories (Ballard-Barbash R, Graubard I, Krebs-Smith SM, Schatzkin A, Thompson FE. Contribution of dieting to the inverse association between energy intake and body mass index. Eur J Clin Nutr. 1996 Feb;50(2):98-106.).

In other words, higher BMI is associated with lower calorie intake.  The researchers conclude that:

“Intermittent energy restriction appeared to be a significant factor in the reduced energy intake reported among overweight women in this sample.”  

The women aren’t lying; they’re dieting. Maybe they’re doing both!

Two-thirds of Americans are overweight or obese.  Apparently, two-thirds of Americans are either lying or dieting, or maybe both.

If you are a lying fat person, we can’t really draw any reasonable conclusions from the epidemiological data we gather about your eating habits. Furthermore, weight loss programs based on “calories in, calories out” are not likely to help you because you lie about what you eat anyway.

If you are a dieting fat person, we can’t really draw any reasonable conclusions from the epidemiological data we gather about your eating habits. Furthermore, weight loss programs based on “calories in, calories out” are not likely to help you because conventional weight loss programs are not likely to help anyone.

It is just a thought, but perhaps is it time to think about whether there are other things—besides normal human metabolism–that may affect “energy balance.” Quick brainstorm list off the top of my head:

  • genetics
  • epigenetics
  • environmental toxins
  • hormonal status
  • lifestage
  • disease state
  • medications
  • infection/inflammation
  • sleep patterns
  • stress
  • gut flora
  • and last but not least, the food you eat

What? you say. The food we eat?

If you want to be obsessed about calories going in and out, it makes sense to figure out which foods might cause fewer calories to go in and which food might cause more calories to go out. We don’t have all the answers—and it is my personal perspective that individual response is what matters most—but, here are a few clues:

In this study, participants who ate eggs for breakfast (with no other deliberate dietary changes) consumed 400 fewer calories over the course of the day than the participants who ate bagels, i.e. calories in went down.


From: Ratliff J, Leite JO, de Ogburn R, Puglisi MJ, VanHeest J, Fernandez ML. Consuming eggs for breakfast influenced plasma glucose and ghrelin, while reducing energy intake during the next 24 hours in adult men. Nutr Res. 2010 Feb;30(2):96-103.

In this study, when participants consumed a diet with reduced carbs and increased fat, resting and total energy expenditure tended to go up compared to when the same participants consumed diets with higher carb and lower fat content, i.e. calories out went up.


From: Ebbeling CB, Swain JF, Feldman HA, Wong WW, Hachey DL, Garcia-Lago E, Ludwig DS. Effects of dietary composition on energy expenditure during weight-lossmaintenance. JAMA. 2012 Jun 27;307(24):2627-34.

So, strangely enough, simply by choosing foods that are specifically NOT recommended in the current low-fat, low-cholesterol, high-carbohydrate diet promoted by the USDA/HHS, you may be able to alter your “energy balance” so that there are fewer calories coming in and more calories going out, without having to change anything else.

It’s time to quit condemning 9-year-old girls to a lifetime of hunger and frustration with “calories in, calories out” dieting, or accusations about them lying about what they eat, or both.

To paraphrase the immortal words of Dr. Suess:

“Calories in, calories out” will you please go now!

The time has come.

The time is now.

Just go.

Go.

Go!

I don’t care how.

“Calories in, calories out”

I don’t care how.

“Calories in, calories out”

Will you please

GO NOW!

Next up: The Mobius strip of policy & the future of nutrition