Tag HHS

The slick “new” Dietary Guidelines

Adele Hite, PhD MPH RD 29 Comments

Because never changing the recommendations means never having to say you’re sorry for 35 years of crappy advice, the 2015 (really 2016, but who’s counting?) Dietary Guidelines repeat the same old-same old “whole grains, fruitsandvegetables, low-fat/fat-free dairy, fish, nuts, and (if you must) lean meat” guidance from years past. Only difference: The new Guidelines are now oozing with vegetable oil.

In the list of recommended foods to include in “a healthy eating pattern,” “oils” now have their own category.
Oil its own food group
For the most part, we are talking Big Oil: canola, corn, peanut, safflower, soybean, and sunflower. Oils that have been chemically extracted, de-gummed, bleached, and deodorized (y’know, stuff you do to dirty diapers). And good luck finding them at your local farmers market.

Big Oil is big business for the U.S. agricultural economy and for the nutrition science academic industry. Alice Lichtenstein, of the 2015 Dietary Guidelines Advisory Committee, has found more creative ways to feed all kinds of oil to hamsters, rats, and people than probably anybody on earth. Corn, canola, soybean, safflower, sunflower, margarine and shortening, even rice bran oil–you name the oily food substance and Alice Slicktenstein has built her career on getting funding for studying it. Most of her work is done at–and funded through–the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts, which is supported by money from, you guessed it, the USDA.  Her research is also supported by numerous grants from the NIH branch of HHS. However, this has nothing to do with the shiny new prominence of oily stuff in the USDA’s and HHS’s new Dietary Guidelines.

To be sure, oil oil everywhere is not the only thing slick about the new Guidelines. The language is pretty slippery too. There’s been a lot of cheering from the press about the “new” direction of the Guidelines, and indeed, some of the things being reported are actually in the Guidelines: The Guidelines have gotten rid of the ridiculous (and possibly dangerous) “1/2 teaspoon of salt a day” limits on sodium for some subpopulations–although the no-more-than 2300 mg (yes, a Whole Teaspoon!) limit should still be–wait for it–taken with a grain of salt.

Despite all arguments otherwise, nutrition–the politics and the science of it–is complicated. In a number of cases, trying to make the ugly stepsister foot of a “consistent public health message” squeeze into the glass slipper of inadequate and contradictory science has the Guidelines talking out of both sides of its oleaginous mouth. Here’s a closer look at what is going on:

1. Limits on cholesterol are gone.
Eh. Sorta kinda not really. It would appropriate to say “numerical” limits on cholesterol are gone, but the language of the DGA is still pretty limiting. As in:

“individuals should eat as little dietary cholesterol as possible”

What’s fun about this is that the Vegamanics are celebrating this as “cholesterol still sucks” while the SatFat Redeemers are all about “Eat them eggs, y’all.” They’re both right.  Or wrong.  Hey, this is nutrition! You don’t really expect a straight answer now, do you?

2. Red meat gets a pass.

It’s true that [lean] meat has not disappeared altogether, and that language about a “sustainable diet” (whatever that means) is not in the Guidelines. At the same time, the Guidelines recommend “lower intakes of meats, including processed meats,” lumping them in the same category as sugar-sweetened food and refined grains. So like the cholesterol issue above, this is getting played as “Evil meat lobby wins” on one side of the debate, and “Meat justice prevails” on the other.

The meat industry is happy to proclaim its support the Guidelines–as long as its product is still in them. If I were the meat folks though, I’d be working to shut the whole process down. If meat is still in the Guidelines, it is not for lack of 35 years of trying to get it out.

3. Limits on fat are gone.
Nope. Limits on “fat” are still there. If you’ve been hearing rumors that we are at the end of the “low-fat” era, and you thought that meant that the Guidelines were going to give the green light to fats–natural fats, fats that you could find at your local farmers market–you would be sadly, profoundly mistaken.

Just like all squares are rectangles, but only some rectangles are squares, all oils are fats, but only some fats are oils. The new Guidelines have been credited with saying, “Hey we’re okay with rectangles” but they are only okay with those rectangles that are squares.  You can eat fat, but only if it’s oil.

Evil fats

So: Fat–as in “saturated fat”– is still evil. For adults, lower limits on “oil” are still 20%–with the exception of a few oils that the DGA folks still don’t like because their fatty acids are mostly saturated. And the upper limit on dietary “oil” as a macronutrient remains at 35% of calories, as it has been since 2005. Only by keeping limits on “oil” low can we manage to cram in the Guidelines’ requisite 45%-65% of calories of carbohydrate into our diets and still have room for protein.

In other words, the USDA hasn’t discarded the “low-fat” diet. They’ve instituted the “low oil” diet. Now you are allowed a whopping 27 grams (about 5 teaspoons) of highly processed and refined, probably not local or within your foodshed, oily oil. Cheers!crisco oil
4. The DGA limits sugar intake.
Nope. It limits “added sugar” intake. That means that a bottle of orange juice, which “naturally” has as much sugar as a bottle of soda, is “good,” while soda is “bad.” Yeah yeah yeah. I hear you out there: “But but but. Orange juice has Vitamin C.” So add some Vitamin C to soda–same difference. Puh-leeze. Sugar is sugar. (I’ll save my “starch is sugar too” rant for another day.)

And all this talk about how Americans “typically exceed” recommendations for added sugar intake? Go look through the past 35 years of Dietary Guidelines. This is the first time ever that there has been an official numerical limit on sugar in any form–added or otherwise. I’m not sure how we could “exceed” something that wasn’t defined in the first place. However, the “Americans don’t follow the Guidelines” story is the best way to avoid confronting the fact that the Guidelines have not worked as intended. USDA/HHS can pretend that all would have been well if those fat stupid Americans had just done the stuff they were (actually not) told to do! Secretary Burwell suggested at the hearings in October that without the Guidelines the rapid rise in obesity rates might have been even rapider …

“We are on the wrong trajectory, but would the trajectory have been worse?”

… though it is hard to see how.  Fat lazy Americans can only cram so many Double Whoppers with Cheese down their gullets at a time, and besides Netflix wasn’t even invented until, like, 1997.

For a bit of perspective, although the 10% cap on “added sugars” is being hailed as some nutrition revolution, the USDA says Americans typically consume 13% of their calories from “added sugars” now. The radical new cap on “added sugars” heralds a (potential) whopping 3% decline in their consumption.  To be replaced by “naturally occurring sugars”? Or possibly more artificial sweeteners? Maybe, beer?

One thing is true about the Guidelines, though. Pretty much everyone hates them. Doesn’t matter where on the nutrition dogma spectrum you look–Marion Nestle or Nina Teicholz–everyone’s complaining.

I don’t like them either, but for reasons I don’t hear about in the press:

“All segments of society—individuals, families, communities, businesses and industries, organizations, governments, and others—can and should “align with the Dietary Guidelines.”

What this means:  The Guidelines have not worked as intended in the past and haven’t changed significantly in this edition, but this isn’t because the whole idea of having a single dietary prescription that will reduce risk of virtually every chronic disease in all Americans no matter their race, gender, age, genetics, lifestyle, etc. etc. etc. is patently ludicrous.  The Guidelines haven’t worked because we haven’t “aligned with” them.

As some snarky person once said, this is all about enforcing your right to eat what the folks behind the Guidelines have determined is good for you. 

“Aligning with the Dietary Guidelines by taking these actions is powerful because it can help change social norms and values and ultimately support a new prevention and healthy lifestyle paradigm that will benefit the U.S. population today as well as future generations.”

What this means:  Making certain behaviors the “norm” through public health dictum is a tried-and-true way for privileged classes to impose their values on the less-privileged.  “Aligning with” the Guidelines will help make eating (and exercising) like rich white people the morally superior choice for everyone.

To paraphrase how one brainless “expert” on public consumption put it many years ago, “Let them eat kale!”

For the rest of us, well, Marion Nestle is right when she says that the Guidelines are a “win” for the processed food industries.  She should know.  She was managing editor of the 1988 Surgeon General’s  Report on Nutrition and Health, which said that processed food created to fit the prevailing definition of “healthy” is exactly what the public needs:

“Food manufacturers can contribute to improving the availability of palatable, easily prepared food products that will help people to follow the [low-fat, high-carbohydrate] dietary principles outlined here.”

The 2015-20120 Dietary Guidelines continue this line of reasoning:

“During the past few decades, food products and menus have notably evolved in response to consumer demands and public health concerns. The food and beverage and food service sectors and settings have a unique opportunity to continue to evolve and better align with the Dietary Guidelines.”

Which means that there is one group that always LUVS the Dietary Guidelines. As Food Navigator-USA puts it:

“The 2015 Guidelines released Jan. 7 create a marketing opportunity for savvy manufacturers and industry stakeholders to promote their products through educational materials that help consumers better understand how to meet the report’s recommendations.”

The Dietary Guidelines have been helping sell “healthy food” to consumers since 1980, just as “healthy food” manufacturers have been helping sell the Guidelines to consumers.  But “healthy food” doesn’t always lead to “healthy people.”  Moronically enough, the new Guidelines recognize that calls for “healthy processed food” might end badly (flashback to CSPI campaigning to add trans fats to food):

“In [developing and reformulating “healthy” products], care should be taken to assess any potential unintended consequences so that as changes are made to better align with the Dietary Guidelines, undesirable changes are not introduced.”

That means when the onslaught of oily, whole-grain, artificially sweetened and flavored food products fails to improve the health of Americans or (heaven forfend!) makes things worse, we know who to blame.

We can blame the American public for not following the Guidelines.  We can blame policymakers for not enforcing them.  And we can blame food manufacturers for introducing “undesirable changes” into the food supply.  But we can’t blame the Guidelines.

They’re too slick for that.

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PS.  I do plan on continuing the conversation started by Jennifer Calihan’s guest post “Low Fat, High Maintenance:  How money buys lean and healthy–plus an alternative path to both.”  If you haven’t read it already, you should (and the comments–good stuff there too). But, I just gotta get a couple of Dietary Guidelines rants out of my system.

Changing the Dietary Guidelines

Adele Hite, PhD MPH RD 28 Comments

If you have been following any of the Dietary Guidelines Advisory Committee’s meetings (who does that anyway? I mean, unless you are a total geek like I am), then you might have noticed that the next Guidelines seem very likely to continue to promote the same nutritional advice that has proven largely ineffective for more than 35 years.

In my other, not-quite-so-snarky, life, I am not Wonder Woman (but oh, what I wouldn’t give for a pair of bracelets of submission). However, I am director of the Healthy Nation Coalition, a loose affiliation of healthcare and public health professionals, scientists, and concerned citizens who think it is time we did nutrition a little differently. Right now, we are creating a coalition of supporters to speak out against the direction the current 2015 Dietary Guidelines are taking and to offer an alternative approach.

This letter will be delivered to the Secretaries of the U.S. Departments of Agriculture and Health and Human Services, selected policymakers, and interested media outlets. We hope to add to the momentum that has been building in the national media calling for a change in our national dietary guidance (see Nina Teicholz’ book, Big Fat Surprise, and her recent op-ed in the Wall Street Journal).

The letter is copied below (or you can use this link to the pdf–the pdf is where all the citations are, because I know how you love citations).

If you wish to sign on, you can use this quick form to add your information to the letter. If you’re interested, but don’t want to read the whole boring letter, check out Mark Sisson’s blog post about it.  It’s lots more fun.

In a nutshell, we are asking for Dietary Guidelines that are geared toward the general public and focused on adequate essential nutrition.

This is not a call for low-carb, high-fat dietary recommendations, or paleo ones, and it takes no stance on the whole “calories in, calories out” versus hormonal regulation etc. etc. issue.  So if you want to criticize this approach, don’t start bitching about low-carb diets or CICO, or I’ll know that you haven’t bothered to actually read this and I won’t feel guilty about deleting your comments.  Beyond that, if you have genuine objections to this approach, suggest a better one–or go away.   What we are doing now isn’t working.  What we need is productive conversation about what to do differently.

Healthy Nation Coalition Letter – 2015 Dietary Guidelines for Americans

Dear Secretary Burwell and Secretary Vilsack,

At the conclusion of the sixth meeting of the 2015 Dietary Guidelines Advisory Committee (DGAC), we write to express concern about the state of federal nutrition policy and its long history of failure in preventing the increase of chronic disease in America. The tone, tenor, and content of the DGAC’s public meetings to date suggest that the 2015 Dietary Guidelines for Americans (DGA) will perpetuate the same ineffective federal nutrition guidance that has persisted for nearly four decades but has not achieved positive health outcomes for the American public.

We urge you to adhere to the initial Congressional mandate that the DGA act as “nutritional and dietary information and guidelines for the general public” and are “based on the preponderance of the scientific and medical knowledge which is current at the time the report is prepared.”

Below we lay out specific objections to the DGA:
· they have contributed to the increase of chronic diseases;
· they have not provided guidance compatible with adequate essential nutrition;
· they represent a narrow approach to food and nutrition inconsistent with the nation’s diverse cultures, ethnicities, and socioeconomic classes;
· they are based on weak and inconclusive scientific data;
· and they have expanded their purpose to issues outside their original mandate.

As you prepare to consider the 2015 DGAC’s recommendations next year, we urge you to fulfill your duty to create the dietary foundation for good health for all Americans by focusing on adequate essential nutrition from whole, nourishing foods, rather than replicating guidance that is clearly failing.

The DGA have contributed to the rapid rise of chronic disease in America.

In 1977, dietary recommendations (called Dietary Goals) created by George McGovern’s Senate Select Committee advised that, in order to reduce risk of chronic disease, Americans should decrease their intake of saturated fat and cholesterol from animal products and increase their consumption of grains, cereal products, and vegetable oils. These Goals were institutionalized as the DGA in 1980, and all DGA since then have asserted this same guidance. During this time period, the prevalence of heart failure and stroke has increased dramatically. Rates of new cases of all cancers have risen. Most notably, rates of diabetes have tripled. In addition, although body weight is not itself a measure of health, rates of overweight and obesity have increased dramatically. In all cases, the health divide between black and white Americans has persisted or worsened.

While some argue that Americans have not followed the DGA, all available data show Americans have shifted their diets in the direction of the recommendations: consuming more grains, cereals, and vegetable oils, while consuming less saturated fat and cholesterol from whole foods such as meat, butter, eggs, and full-fat milk. Whether or not the public has followed all aspects of DGA guidance does not absolve the U.S. Departments of Agriculture (USDA) and Health and Human Services (DHHS) from ensuring that the dietary guidance provided to Americans first and foremost does no harm.

The DGA fail to provide guidance compatible with essential nutrition needs.

The 1977 Dietary Goals marked a radical shift in federal dietary guidance. Before then, federal dietary recommendations focused on foods Americans were encouraged to eat in order to acquire adequate nutrition; the DGA focus on specific food components to limit or avoid in order to prevent chronic disease. The DGA have not only failed to prevent chronic disease, in some cases, they have failed to provide basic guidance consistent with nutritionally adequate diets.
· Maillot, Monsivais, and Drewnowski (2013) showed that the 2010 DGA for sodium were incompatible with potassium guidelines and with nutritionally adequate diets in general.
· Choline was recognized as an essential nutrient in 1998, after the DGA were first created. It is crucial for healthy prenatal brain development. Current choline intakes are far below adequate levels, and choline deficiency is thought to contribute to liver disease, atherosclerosis and neurological disorders. Eggs and meat, two foods restricted by current DGA recommendations, are important sources of choline. Guidance that limits their consumption thus restricts intake of adequate choline.
· In young children, the reduced fat diet recommend by the DGA has also been linked to lower intakes of a number of important essential nutrients, including calcium, zinc, and iron.

Following USDA and DHHS guidance should not put the most vulnerable members of the population at risk for nutritional inadequacy. DGA recommendations should be emphasizing whole foods that provide essential nutrition, rather than employing a reductionist approach based on single food components to exclude these foods from the diet.

The DGA’s narrow approach to food and health is inappropriate for a diverse population.

McGovern’s 1977 recommendations were based on research and food patterns from middle class Caucasian American populations. Since then, diversity in America has increased, while the DGA have remained unchanged. DGA recommendations based on majority-white, high socioeconomic status datasets have been especially inappropriate for minority and low-income populations. When following DGA recommendations, African American adults gain more weight than their Caucasian counterparts, and low-income individuals have increased rates of diabetes, hypertension, and high cholesterol. Long-standing differences in environmental, genetic and metabolic characteristics may mean recommendations that are merely ineffective in preventing chronic disease in white, middle class Americans are downright detrimental to the long-term health of black and low-income Americans.

The DGA plant-based diet not only ignores human biological diversity, it ignores the diversity of American foodways. DGA guidance rejects foods that are part of the cultural heritage of many Americans and indicates that traditional foods long considered to be important to a nourishing diet should be modified, restricted, or eliminated altogether: ghee (clarified butter) for Indian Americans; chorizo and eggs for Latino Americans; greens with fatback for Southern and African Americans; liver pâtés for Jewish and Eastern European Americans.

Furthermore, recommendations to prevent chronic disease that focus solely on plant-based diets is a blatant misuse of public health authority that has stymied efforts of researchers, academics, healthcare professionals, and insurance companies to pursue other dietary approaches adapted to specific individuals and diverse populations, specifically, the treatment of diabetes with reduced-carbohydrate diets that do not restrict saturated fat. In contradiction of federal law, the DGA have had the effect of limiting the scope of medical nutrition research sponsored by the federal government to protocols in line with DGA guidance.

The DGA are not based on the preponderance of current scientific and medical knowledge.

The science behind the current DGA recommendations is untested and inconsistent. Scientific disagreements over the weakness of the evidence used to create the 1977 Dietary Goals have never been settled. Recent published accounts have raised questions about whether the scientific process has been undermined by politics, bias, institutional inertia, and the influence of interested industries.

Significant scientific controversy continues to surround specific recommendations that:
1. Dietary saturated fat increases the risk of heart disease: Two recent meta-analyses concluded there is no strong scientific support for dietary recommendations that restrict saturated fat. Studies cited by the 2010 DGAC Report demonstrate that in some populations, lowering dietary saturated fat actually worsens some biomarkers related to heart disease.
2. Dietary cholesterol increases the risk of heart disease: Due to a lack of evidence, nearly all other Western nations have dropped their limits on dietary cholesterol. In 2013, a joint panel of the American Heart Association and the American College of Cardiology did the same.
3. Polyunsaturated vegetable oils reduce the risk of heart disease and should be consumed as the primary source of dietary fat: Recent research renews concerns raised in response to the 1977 Dietary Goals that diets high in the omega-6 fatty acids present in vegetable oils may actually increase risk of chronic disease or death.
4. A diet high in carbohydrate, including whole grains, reduces risk of chronic disease: Clinical trials have demonstrated that diets with lower carbohydrate content improve risk factors related to heart disease and diabetes. Janet King, Chair of the 2005 DGAC, has stated that “evidence has begun to accumulate suggesting that a lower intake of carbohydrate may be better for cardiovascular health.”
5. A low-sodium diet reduces risk of chronic disease: A 2013 Institute of Medicine report concludes there is insufficient evidence to recommend reducing sodium intake to the very low levels set by the DGA for African-Americans of any age and adults over 50.

In all of these cases, contradictory evidence has been ignored in favor of maintaining outdated recommendations that have failed to prevent chronic disease.

More generally, “intervention studies, where diets following the Dietary Guidelines are fed long-term to human volunteers, do not exist,” and food patterns recommended by the DGA “have not been specifically tested for health benefits.” The observational research being used for much of the current DGAC activities may suggest possible associations between diet and disease, but such hypotheses must then be evaluated through rigorous testing. Applying premature findings to public health policy without adequate testing may have resulted in unintended negative health consequences for many Americans.

The DGA have overstepped their original purpose.

The DGA were created to provide nutrition information to all Americans. However, the current 112-page DGA, with 29 recommendations, are considered too complex for the general public and are directed instead at policymakers and healthcare professionals, contradicting their Congressional mandate.

Federal dietary guidance now goes far beyond nutrition information. It tells Americans how much they should weigh and how to lose weight, even recommending that each American write down everything that is eaten on a daily basis. This focus on obesity and weight loss has contributed to extensive and unrecognized “collateral damage”: fat-shaming, eating disorders, discrimination, and poor health from restrictive food habits. At the same time, researchers at the Centers for Disease Control have shown that overweight and obese people are often as healthy as their “normal” weight counterparts. Guidance related to body weight should meet individual health requirements and be given by a trained healthcare practitioner, not be dictated by federal policy.

The DGA began as an unmandated consumer information booklet. They are now a powerful political document that regulates a vast array of federal programs and services, dictates nationwide nutrition standards, influences agricultural policies and health-related research, and directs how food manufacturers target consumer demand. Despite their broad scope, the DGA are subject to no evaluation or accountability process based on health outcomes. Such an evaluation would demonstrate that they have failed to fulfill their original goal: to decrease rates of chronic disease in America.

Despite this failure, current DGAC proceedings point to an expansion of their mission into sustainable agriculture and environmental concerns. While these are important issues, they demonstrate continued “mission creep” of the DGA. The current narrow DGA focus on plant-based nutrition suggests a similarly biased approach will be taken to environmental issues, disregarding centuries of traditional farming practices in which livestock play a central role in maintaining soil quality and ecological balance. Instead of warning Americans not to eat eggs and meat due to concerns about saturated fat, cholesterol, and obesity, it is foreseeable that similar warnings will be given, but for “environmental” reasons. This calls for an immediate refocusing of the purpose of the DGA and a return to nutritional basics.

Solution: A return to essential nutrition guidance

As our nation confronts soaring medical costs and declining health, we can no longer afford to perpetuate guidelines that have failed to fulfill their purpose. Until and unless better scientific support is secured for recommendations regarding the prevention of chronic disease, the DGA should focus on food-based guidance that assists Americans in acquiring adequate essential nutrition.

Shifting the focus to food-based guidance for adequate essential nutrition will create DGA that:
· are based on universally accepted and scientifically sound nutritional principles: Although more knowledge is needed, the science of essential nutrient requirements is firmly grounded in clinical trials and healthcare practice, as well as observational studies.
· apply to all Americans: Essential nutrition requirements are appropriate for everyone. Lack of essential nutrients will lead without exception to diseases of deficiency.
· include traditionally nourishing foods: A wide variety of eating patterns can provide adequate essential nutrition; no nourishing dietary approaches or cultural food traditions would be excluded or discouraged.
· expand opportunities for research: With dietary guidance focused on adequate essential nutrition, researchers, healthcare providers, and insurance companies may pursue dietary programs and practices tailored to individual risk factors and diverse communities without running afoul of the DGA and while ensuring that basic nutrition needs are always met.
· direct attention towards health and well-being: Focus will be directed away from intermediate markers, such as weight, which may be beyond individual control, do not consistently predict health outcomes, and are best dealt with in a healthcare setting.
· are clear, concise, and useful to the public: Americans will be able to understand and apply such guidance to their own dietary patterns, minimizing the current widespread confusion and resentment resulting from federal dietary guidance that is poorly grounded in science.

It is the duty of USDA and DHHS leadership to end the use of controversial, unsuccessful and discriminatory dietary recommendations. USDA and DHHS leadership must refuse to accept any DGA that fail to establish federal nutrition policy based on the foundation of good health: adequate essential nutrition from wholesome, nourishing foods. It is time to create DGA that work for all Americans.

 

Dietary Guidelines for Americans: We don’t need no stinkin’ science

Adele Hite, PhD MPH RD 50 Comments

I know, I know. I never post. I never call. I don’t bring you flowers. It’s a wonder we’re still together. I have the usual list of excuses:

1) GRADUATE SCHOOL

But before I disappear off the face of the interwebz once again, I thought I share with you a quickie post on the science behind our current Dietary Guidelines. Even as we speak, the USDA and DHHS are busy working on the creation of the new 2015 Dietary Guidelines for Americans, which are shaping up to be the radically conservative documents we count on them to be.

For just this purpose, the USDA has set up a very large and impressive database called the Nutrition Evidence Libbary (NEL), where it conducts “systematic reviews to inform Federal nutrition policy and programs.” NEL staff collaborate with stakeholders and leading scientists using state-of-the-art methodology to objectively review, evaluate, and synthesize research to answer important diet-related questions in a manner that allows them to reach a conclusion that they’ve previously determined is the one they want.

It’s a handy skill to master. Here’s how it’s done.

The NEL question:

What is the effect of saturated fat intake on increased risk of cardiovascular disease or type 2 diabetes?

In the NEL, they break the evidence up into “cardiovascular” and “diabetes” so I’ll do the same, which means we are really asking: What is the effect of saturated fat (SFA) intake on increased risk of cardiovascular disease?

Spoiler alert–here’s the answer: “Strong evidence” indicates that we should reduce our intake of saturated fat (from whole foods like eggs, meat, whole milk, and butter) in order to reduce risk of heart disease. As Gomer Pyle would say, “SUR-PRIZE, SUR-PRIZE.”

Aaaaaaaand . . . here’s the evidence:

The 8 studies rated “positive quality” are in blue; the 4 “neutral quality” studies are in gray. The NEL ranks the studies as positive and neutral (less than positive?), but treats them all the same in the review. Fine. Whateverz.

According to the exclusion criteria for this question, any study with a dropout rate of more than 20% should be eliminated from the review. These 4 studies have dropout rates of more than 20%. They should have been excluded. They weren’t, so we’ll exclude them now.

Also, according to NEL exclusion criteria for this question, any studies that substituted fat with carbohydrate or protein, instead of comparing types of fat, should be excluded. Furtado et al 2008 does not address the question of varying levels of saturated fat in the diet. In fact, saturated fat levels were held constant–at 6% of calories–for each experimental diet group. So, let’s just exclude this study too.

One study–Azadbakht et al 2007–was conducted on teenage subjects with hypercholesterolemia. Since the U.S. Dietary Guidelines are not meant to treat medical conditions and are meant for the entire population, this study should not have been included in the analysis. Furthermore, the dietary intervention not only lowered saturated fat content of the diet but cholesterol content too. So it would be difficult to attribute any outcomes only to changes in saturated fat intake. The study should not have been included, so let’s take care of that for those NEL folks.

 

In one study–Buonacorso et al 2007–total cholesterol levels did not change when dietary saturated fat was increased: “Plasma TC [total cholesterol] and triacylglycerol levels were NS [not significantly] changed by the diets, by time (basal vs. final test), or period (fasting vs. post-prandial) according to repeated-measures analysis.” This directly contradicts the conclusion of the NEL. Hmmmm. So let’s toss this study and see what’s left.

In these four studies, higher levels of saturated fat in the diet made some heart disease risk factors get worse, but other risk factors got better. So the overall effect on heart disease risk was mixed or neutral. As a result, these studies do not support the NEL conclusion that saturated fat should be reduced in order to reduce risk of heart disease.

 

That leaves one lone study. A meta-analysis of eleven observational studies. Seeing as the whole point of a meta-analysis is to combine studies with weak effects to see if you end up with a strong one, if saturated fat was really strongly associated with heart disease, we should see that, right? Right. What this meta-analysis found was that among women over 60, there is no association between saturated fat and coronary events or deaths. Among adult men of any age, there is no association between saturated fat and coronary events or deaths. Only in women under the age of 60 is there is a small inverse association between risk of coronary events or deaths and the reduction of saturated fat in the diet. That sounds like it might be bad news—at least for women under 60—but this study also found a positive association between monounsaturated fats—you know, the “good fat,” like you would find in olive oil—and risk of heart disease. If you take the results of this study at face value–which I wouldn’t recommend–then olive oil is as bad for you as butter.

So there’s your “strong” evidence for the conclusion that saturated fat increases risk of heart disease.

 

Just recently, Frank Hu of the 2015 Dietary Guidelines Advisory Committee was asked what we should make of the recent media attention to the idea that saturated fat is not bad for you after all (see this video at 1:06:00). Dr. Hu reassured us that, no, saturated fat still kills. He went on to say that the evidence to prove this, provided primarily by a meta-analysis created by USDA staffers (and we all know how science-y they can be), is MUCH stronger than that used by the 2010 Committee.

Well, all I can say is:  it must be.  Because it certainly couldn’t be any weaker.

 

 

As the Calories Churn (Episode 1): Nooooo, not the carbs!!!

Adele Hite, PhD MPH RD 69 Comments

Oh the drama!  Some of the current hyperventilating in the alternative nutrition community–sugar is toxic, insulin is evil, vegetable oils give you cancer, and running will kill you–has, much to my dismay, made the alternative nutrition community sound as shrill and crazed as the mainstream nutrition one.

When you have self-appointed nutrition experts food writers like Mark Bittman agreeing feverishly with a pediatric endocrinologist with years of clinical experience like Robert Lustig, we’ve crossed over into some weird nutrition Twilight Zone where fact, fantasy, and hype all swirl together in one giant twitter feed of incoherence meant, I think, to send us into a dark corner where we can do nothing but nibble on organic kale, mumble incoherently about inflammation and phytates, and await the zombie apocalypse.

No, carbohydrates are not evil—that’s right, not even sugar. If sugar were rat poison, one trip to the county fair in 4th grade would have killed me with a cotton candy overdose. Neither is insulin, now characterized as the serial killer of hormones (try explaining that to a person with type 1 diabetes).

But that doesn’t mean that 35 years of dietary advice to increase our grain and cereal consumption, while decreasing our fat and saturated fat consumption has been a good idea.

I have gotten rather tired of seeing this graph used as a central rationale for arguing that the changes in total carbohydrate intake over the past 30 years have not contributed to the rising rates of obesity.


The argument takes shapes on 2 fronts:

1) We ate 500 grams of carbohydrate per day in 1909 and 500 grams in 1997 and WE WEREN’T FAT IN 1909!

2) The other part of the argument is that the TYPE of carbohydrate has shifted over time. In 1909, we ate healthy, fiber-filled unrefined and unprocessed types of carbohydrates. Not like now.

Okay, let’s take closer look at that paper, shall we?  And then let’s look at what really matters:  the context.

The data used to make this graph are not consumption data, but food availability data. This is problematic in that it tells us how much of a nutrient was available in the food supply in any given year, but does not account for food waste, spoilage, and other losses. And in America, we currently waste a lot of food. 

According to the USDA, we currently lose over 1000 calories in our food supply–calories that don’t make it into our mouths.  Did we waste the same percentage of our food supply across the entire century? Truth is, we don’t know and we are not likely to find out—but I seriously doubt it. My mother and both my grandmothers—with memories of war and rationing fresh in their minds—would be no more likely to throw out anything remotely edible as they would be to do the Macarena. My mother has been known to put random bits of leftover food in soups, sloppy joes, and—famously—pancake batter. To this day, should your hand begin to move toward the compost bucket with a tablespoon of mashed potatoes scraped from the plate of a grandchild shedding cold virus like it was last week’s fashion, she will throw herself in front of the bucket and shriek, “NOOOOOO! Don’t throw that OUT! I’ll have that for lunch tomorrow.”

You know what this means folks: in 1909, we were likely eating MORE carbohydrate than we are today. (Or maybe in 1909, all those steelworkers pulling 12 hour days 7 days a week, just tossed out their sandwich crusts rather than eat them. It could happen.)

BUT–as with butts all over America including mine, it’s a really Big BUT: How do I explain the fact that Americans were eating GIANT STEAMING HEAPS OF CARBOHYDRATES back in 1909—and yet, and yet—they were NOT FAT!!??!!

Okay. Y’know. I’m up for this one. Not only is problematic to the point of absurdity to compare food availability data from the early 1900s to our current food system, life in general was a little different back then. At the turn of the century,

  • average life expectancy was around 50
  • the nation had 8,000 cars
  • and about 10 miles of paved roads.

In 1909, neither assembly lines nor the Titanic had happened yet.

The labor force looked a little different too:Labor force 1900 - 2000

Primary occupations made up the largest percentage of male workers (42%)—farmers, fisherman, miners, etc.—what we would now call manual laborers. Another 21% were “blue collar” jobs, craftsmen, machine operators, and laborers whose activities in those early days of the Industrial Revolution, before many things became mechanized, must have required a considerable amount of energy. And not only was the work hard, there was a lot of it. At the turn of the century, the average workweek was 59 hours, or close to 6 10-hour days. And it wasn’t just men working. As our country shifted from a rural agrarian economy to a more urban industrialized one, women and children worked both on the farms and in the factories.

This is what is called “context.”

In the past, nutrition epidemiologists have always considered caloric intake to be a surrogate marker for activity level. To quote Walter Willett himself:

“Indeed, in most instances total energy intake can be interpreted as a crude measure of physical activity . . . ” (in: Willett, Walter. Nutritional Epidemiology. Oxford University Press, 1998, p. 276).

It makes perfect sense that Americans would have a lot of carbohydrate and calories in their food supply in 1909. Carbohydrates have been—and still are—a cheap source of energy to fuel the working masses. But it makes little sense to compare the carbohydrate intake of the labor force of 1909 to the labor force of 1997, as in the graph at the beginning of this post (remember the beginning of this post?).

After decades of decline, carbohydrate availability experienced a little upturn from the mid 1960s to the late 1970s, when it began to climb rapidly. But generally speaking, carbohydrate intake was lower during that time than at any point previously.

I’m not crazy about food availability data, but to be consistent with the graph at the top of the page, here it is.

Data based on per capita quantities of food available for consumption:

1909 1975 Change
Total calories 3500 3100 -400
Carbohydrate calories 2008 1592 -416
Protein calories 404 372 -32
Total fat calories 1098 1260 +162
Saturated fat (grams) 52 47 -5
Mono- and polyunsaturated fat (grams) 540 738 +198
Fiber (grams) 29 20 -9

To me, it looks pretty much like it should with regard to context.  As our country went from pre- and early industrialized conditions to a fully-industrialized country of suburbs and station wagons, we were less active in 1970 than we were in 1909, so we consumed fewer calories. The calories we gave up were ones from the cheap sources of energy—carbohydrates—that would have been most readily available in the economy of a still-developing nation. Instead, we ate more fat.

We can’t separate out “added fats” from “naturally-present fats” from this data, but if we use saturated fat vs. mono- and polyunsaturated fats as proxies for animal fats vs. vegetable oils (yes, I know that animal fats have lots of mono- and polyunsaturated fats, but alas, such are the limitations of the dataset), then it looks like Americans were making use of the soybean oil that was beginning to be manufactured in abundance during the 1950s and 1960s and was making its way into our food supply.  (During this time, heart disease mortality was decreasing, an effect likely due more to warnings about the hazards of smoking, which began in earnest in 1964, than to dietary changes; although availability of unsaturated fats went up, that of saturated fats did not really go down.)

As for all those “healthy” carbohydrates that we were eating before we started getting fat? Using fiber as a proxy for level of “refinement” (as in the graph at the beginning of this post—remember the beginning of this post?), we seemed to be eating more refined carbohydrates in 1975 than in 1909—and yet, the obesity crisis was still yet a gleam in Walter Willett’s eyes.

While our lives in 1909 differed greatly from our current environment, our lives in the 1970s were not all that much different than they are now. I remember. As much as it pains me to confess this, I was there. I wore bell bottoms. I had a bike with a banana seat (used primarily for trips to the candy store to buy Pixie Straws). I did macramé. My parents had desk jobs, as did most adults I knew. No adult I knew “exercised” until we got new neighbors next door. I remember the first time our new next-door neighbor jogged around the block. My brothers and sister and I plastered our faces to the picture window in the living room to scream with excitement every time she ran by; it was no less bizarre than watching a bear ride a unicycle.

In 1970, more men had white-collar than blue-collar jobs; jobs that primarily consisted of manual labor had reached their nadir. Children were largely excluded from the labor force, and women, like men, had moved from farm and factory jobs to more white (or pink) collar work. The data on this is not great (in the 1970s, we hadn’t gotten that excited about exercise yet) but our best approximation is that about 35% of adults–one of whom was my neighbor–exercised regularly, with “regularly” defined as “20 minutes at least 3 days a week” of moderately intense exercise.  (Compare this definition, a total of 60 minutes a week, to the current recommendation, more than double that amount, of 150 minutes a week.)

Not too long ago, the 2000 Dietary Guidelines Advisory Committee (DGAC) recognized that environmental context—such as the difference between America in 1909 and America in 1970—might lead to or warrant dietary differences:

“There has been a long-standing belief among experts in nutrition that low-fat diets are most conducive to overall health. This belief is based on epidemiological evidence that countries in which very low fat diets are consumed have a relatively low prevalence of coronary heart disease, obesity, and some forms of cancer. For example, low rates of coronary heart disease have been observed in parts of the Far East where intakes of fat traditionally have been very low. However, populations in these countries tend to be rural, consume a limited variety of food, and have a high energy expenditure from manual labor. Therefore, the specific contribution of low-fat diets to low rates of chronic disease remains uncertain. Particularly germane is the question of whether a low-fat diet would benefit the American population, which is largely urban and sedentary and has a wide choice of foods.” [emphasis mine – although whether our population in 2000 was largely “sedentary” is arguable]

The 2000 DGAC goes on to say:

“The metabolic changes that accompany a marked reduction in fat intake could predispose to coronary heart disease and type 2 diabetes mellitus. For example, reducing the percentage of dietary fat to 20 percent of calories can induce a serum lipoprotein pattern called atherogenic dyslipidemia, which is characterized by elevated triglycerides, small-dense LDL, and low high-density lipoproteins (HDL). This lipoprotein pattern apparently predisposes to coronary heart disease. This blood lipid response to a high-carbohydrate diet was observed earlier and has been confirmed repeatedly. Consumption of high-carbohydrate diets also can produce an enhanced post-prandial response in glucose and insulin concentrations. In persons with insulin resistance, this response could predispose to type 2 diabetes mellitus.

The committee further held the concern that the previous priority given to a “low-fat intake” may lead people to believe that, as long as fat intake is low, the diet will be entirely healthful. This belief could engender an overconsumption of total calories in the form of carbohydrate, resulting in the adverse metabolic consequences of high carbohydrate diets. Further, the possibility that overconsumption of carbohydrate may contribute to obesity cannot be ignored. The committee noted reports that an increasing prevalence of obesity in the United States has corresponded roughly with an absolute increase in carbohydrate consumption.” [emphasis mine]

Hmmmm. Okay, folks, that was in 2000—THIRTEEN years ago. If the DGAC was concerned about increases in carbohydrate intake—absolute carbohydrate intake, not just sugars, but sugars and starches—13 years ago, how come nothing has changed in our federal nutrition policy since then?

I’m not going to blame you if your eyes glaze over during this next part, as I get down and geeky on you with some Dietary Guidelines backstory:

As with all versions of the Dietary Guidelines after 1980, the 2000 edition was based on a report submitted by the DGAC which indicated what changes should be made from the previous version of the Guidelines. And, as will all previous versions after 1980, the changes in the 2000 Dietary Guidelines were taken almost word-for-word from the suggestions given by the scientists on the DGAC, with few changes made by USDA or HHS staff. Although HHS and USDA took turns administrating the creation of the Guidelines, in 2000, no staff members from either agency were indicated as contributing to the writing of the final Guidelines.

But after those comments in 2000 about carbohydrates, things changed.

Beginning with the 2005 Dietary Guidelines, HHS and USDA staff members are in charge of writing the Guidelines, which are no longer considered to be a scientific document whose audience is the American public, but a policy document whose audience is nutrition educators, health professionals, and policymakers. Why and under whose direction this change took place is unknown.

The Dietary Guidelines process doesn’t have a lot of law holding it up. Most of what happens in regard to the Guidelines is a matter of bureaucracy, decision-making that takes place within USDA and HHS that is not handled by elected representatives but by government employees.

However, there is one mandate of importance: the National Nutrition Monitoring and Related Research Act of 1990, Public Law 445, 101st Cong., 2nd sess. (October 22, 1990), section 301. (P.L. 101-445) requires that “The information and guidelines contained in each report required under paragraph shall be based on the preponderance of the scientific and medical knowledge which is current at the time the report is prepared.”

The 2000 Dietary Guidelines were (at least theoretically) scientifically accurate because scientists were writing them. But beginning in 2005, the Dietary Guidelines document recognizes the contributions of an “Independent Scientific Review Panel who peer reviewed the recommendations of the document to ensure they were based on a preponderance of scientific evidence.” [To read the whole sordid story of the “Independent Scientific Review Panel,” which appears to neither be “independent” nor to “peer-review” the Guidelines, check out Healthy Nation Coalition’s Freedom of Information Act results.]  Long story short:  we don’t know who–if anyone–is making sure the Guidelines are based on a complete and current review of the science.

Did HHS and USDA not like the direction that it looked like the Guidelines were going to take–with all that crazy talk about too many carbohydrates – and therefore made sure the scientists on the DGAC were farther removed from the process of creating them?

Hmmmmm again.

Dr. Janet King, chairwoman of the 2005 DGAC had this to say, after her tenure creating the Guidelines was over: “Evidence has begun to accumulate suggesting that a lower intake of carbohydrate may be better for cardiovascular health.”

Dr. Joanne Slavin, a member of the 2010 DGAC had this to say, after her tenure creating the Guidelines was over: “I believe fat needs to go higher and carbs need to go down,” and “It is overall carbohydrate, not just sugar. Just to take sugar out is not going to have any impact on public health.”

It looks like, at least in 2005 and 2010, some well-respected scientists (respected well enough to make it onto the DGAC) thought that—in the context of our current environment—maybe our continuing advice to Americans to eat more carbohydrate and less fat wasn’t such a good idea.

I think it is at about this point that I begin to hear the wailing and gnashing of teeth of those who don’t think Americans ever followed this advice to begin with, because—goodness knows—if we had, we wouldn’t be so darn FAT!

So did Americans follow the advice handed out in those early dietary recommendations? Or did Solid Fats and Added Sugars (SoFAS—as the USDA/HHS like to call them—as in “get up offa yur SoFAS and work your fatty acids off”) made us the giant tubs of lard that we are just as the USDA/HHS says they did?

Stay tuned for the next episode of As the Calories Churn, when I attempt to settle those questions once and for all.  And you’ll hear a big yellow blob with stick legs named Timer say, “I hanker for a hunk of–a slab or slice or chunk of–I hanker for a hunk of cheese!”

The NaCl Debacle Part 2: We don’t need no stinkin’ science!

Adele Hite, PhD MPH RD 101 Comments

Sodium-Slashing Superheroes Low-Sodium Larry and his bodacious side-kick Linda “The Less Salt the Better” Van Horn team up to protect Americans from the evils lurking in a teaspoon of salt!
(Drawings courtesy of Butcher Billy)

Yesterday, we found our Sodium-Slashing Superheroes Larry and Linda determined to make sure that no American endangered his/her health by ingesting more than ¾ of a teaspoon of salt a day. But recently, an Institute of Medicine report determined that recommendations to reduce sodium intake to such low levels provided no health benefits and could be detrimental to the health of some people. [In case you missed it and your job is really boring, you can read Part 1 of the NaCl Debacle here.]

Our story picks up as the 2010 USDA/HHS Dietary Guidelines Advisory Committee, fearlessly led by Linda and Larry, arrives at the foregone conclusion that most, if not all, US adults would (somehow) benefit from reducing their sodium intake to 1500 mg/day.  The American Heart Association, in a report written by—surprise!—Larry and Linda, goes on to state that “The health benefits [of reducing sodium intake to 1500 mg/day] apply to Americans in all groups, and there is no compelling evidence to exempt special populations from this public health recommendation.”

Does that mean there is “compelling evidence” to include special populations, or for that matter ordinary populations, in this 1500 mg/day recommendation? No, but who cares?

Does that mean there is science to prove that “excess” sodium intake (i.e. more than ¾ of a teaspoon of salt a day) leads to high blood pressure and thus cardiovascular disease, or that salt makes you fat, or that sodium consumption will eventually lead to the zombie apocalypse? No, no, and no—but who cares?

Larry and Linda KNOW that salt is BAD. Science? They don’t need no stinkin’ science.

Because the one thing everyone seems to be able to agree on is that the science on salt does indeed stink. The IOM report has had to use many of the same methodologically-flawed studies available to the 2010 Dietary Guidelines Advisory Committee, full of the same confounding, measurement error, reverse causation and lame-ass dietary assessment that we know and love about all nutrition epidemiology studies.  But the 2010 Dietary Guidelines Advisory Committee didn’t actually bother to look at these studies.

Why not?  (And let me remind you that the Dietary Guidelines folks usually <heart> methodologically-flawed study designs, full of confounding, measurement error, reverse causation and lame-ass dietary assessment.)

First, a little lesson in how the USDA/HHS folks create dietary guidance meant to improve the health and well-being of the American people:

  1. Take a clinical marker, whose health implications are unclear, but whose levels we can measure cheaply and easily (like blood pressure, cholesterol, weight).
  2. Suggest that this marker—like Karnac the Magnificent—can somehow predict risk of a chronic disease whose origins are multiple and murky (like obesity, heart disease, cancer).
  3. Use this suggestion to establish some arbitrary clinical cut offs for when this marker is “good” and “bad.” (Note to public health advocacy organizations: Be sure to frequently move those goalposts in whichever direction requires more pharmaceuticals to be purchased from the companies that sponsor you.)
  4. Find some dietary factor that can easily and profitably be removed from our food supply, but whose intake is difficult to track (like saturated fat, sodium, calories).
  5. Implicate the chosen food factor in the regulation of the arbitrary marker, the details of which we don’t quite understand. (How? Use observational data—see methodological flaws above—but hunches and wild guesses will also work.)
  6. Create policy that insists that the entire population—including people who, by the way, are not (at least at this point) fat, sick or dead—attempt to prevent this chronic disease by avoiding this particular dietary factor. (Note to public health advocacy organizations: Be sure to offer food manufacturers the opportunity to have the food products from which they have removed the offensive component labeled with a special logo from your organization—for a “small administrative fee,” of course.)
  7. Commence collecting weak, inconclusive, and inconsistent data to prove that yes indeedy this dietary factor we can’t accurately measure does in fact have some relationship to this arbitrary clinical marker, whose regulation and health implications we don’t fully understand.
  8. Finally—here’s the kicker—measure the success of your intervention by whether or not people are willing to eat expensive, tasteless, chemical-filled food devoid of the chosen food factor in order to attempt to regulate the arbitrary clinical marker.
  9. Whatever you do, DO NOT EVER measure the success of your intervention by looking at whether or not attempts to follow your intervention has made people fat, sick, or dead in the process.
  10. Ooops. I think I just described the entire history of nutrition epidemiology of chronic disease.

Blood pressure is easy to measure, but we don’t always know what causes it to go up (or down). There is no real physiological difference between having a blood pressure reading of 120/80, which will get you a diagnosis of “pre-hypertension” and a fistful of prescriptions, and a reading of 119/79, which won’t.  Blood pressure is not considered to be a “distinct underlying cause of death,” which means that, technically, no one ever dies of blood pressure (high or low). We certainly don’t know how to disentangle the effects of lowering dietary sodium on blood pressure from other effects (like weight loss) that may be related to dietary changes that are a part of an attempt to lower sodium (and we have an embarrassingly hard time collecting accurate dietary intake information from Food Fantasy Questionnaires anyway). We also know that individual response to sodium varies widely.

So doesn’t it make perfect sense that the folks at the USDA/HHS should ignore science that investigates the relationship between sodium intake and whether or not a person stayed out of the hospital, had a heart attack, or up and died? Well, it doesn’t to me, but nevertheless the USDA/HHS has remained obsessively fixated on one thing and one thing only, what effects reducing sodium has on blood pressure,  and they pay not one whit of attention to what effects reducing sodium has on, say, aliveness.

So let’s just get this out there and agree to agree: reducing sodium in most cases will reduce blood pressure.  But then, just to be clear, so will dismemberment, dysentery, and death.  We can’t just assume that lowering sodium will only affect blood pressure or will only positively affect health (I mean, we can’t unless we are Larry or Linda). Recent research, which prompted the IOM review, indicates that reducing sodium will also increase triglyceride levels, insulin resistance, and sympathetic nervous system activity. For the record, clinicians generally don’t consider these to be good things.

This may sound radical but in their review of the evidence, the IOM committee decided to do a few things differently.

First, they gave more weight to studies that determined sodium intake levels through multiple high-quality 24-hour urine collections. Remember, this is Low-Sodium Larry’s favorite way of estimating intake.

Also, they did not approach the data with a predetermined “healthy” range already established in their brains. Because of the extreme variability in intake levels among population groups, they decided to—this is crazy, I know—let the outcomes speak for themselves.

Finally, and most importantly, in the new IOM report, the authors, unlike Larry and Linda, focused on—hold on to your hats, folks!—actual health outcomes, something the Dietary Guidelines Have. Never. Done. Ever.

The IOM committee found, in a nutshell:

“that evidence from studies on direct health outcomes is inconsistent and insufficient to conclude that lowering sodium intakes below 2,300 mg per day either increases or decreases risk of CVD outcomes (including stroke and CVD mortality) or all-cause mortality in the general U.S. population.”

In other words, there is no science to indicate that we all need to be consuming less than ¾ of a teaspoon of salt a day. Furthermore, while there may be some subpopulations that may benefit from sodium reduction, reducing sodium intake to 1500 mg/day may increase risk of adverse health outcomes for people with congestive heart failure, diabetes, chronic kidney disease, or heart disease. (If you’d like to wallow in some of the studies reviewed by the IOM, I’ve provided the Reader’s Digest Condensed Version at the bottom of the page.)

Of course, the American Heart Association, eager to provide the public with the most up-to-date recommendations about heart health as long as they don’t contradict outdated recommendations of which the AHA is fond, responded to the IOM report by saying, “The American Heart Association is not changing its position. The association rejects the Institute of Medicine’s conclusions because the studies on which they were based had methodological flaws.”

Um, hello AHA? Exactly what completely non-existent, massive, highly-controlled and yet highly-generalizable randomized controlled trials about sodium intake and health effects were you planning on using to make your case? I believe it was the AHA that mentioned that “It is well-known, however, that such trials are not feasible because of logistic, financial, and often ethical considerations.” Besides, I don’t know what the AHA is whining about. The quality of the science hardly matters if you are not going to pay any attention to it in the first place.

No, folks that giant smacking sound you hear is not my head on my keyboard. That was the sound of science crashing into a giant wall of Consistent Public Health Message. Apparently, those public health advocates at the AHA seem to think that changing public health messages—even when they are wrong—confuses widdle ol’ Americans. The AHA—and the USDA/HHS team—doesn’t want us to have to worry our pretty little heads about all that crazy scientifical stuff with big scary words and no funny pictures or halftime shows.

Frankly, I appreciate that. I hate to have my pretty little head worried. But there’s one other problem with this particular Consistent Public Health Message. Not only is there no science to back it up; not only is it likely to be downright detrimental to the health of certain groups of people; not only is it likely to introduce an arsenal of synthetic chemical salt-replacements that will be consumed at unprecedented levels without testing for negative interactions or toxicities (remember how well that worked out when we replaced saturated fat with partially-hydrogenated vegetable oils?)—it is, apparently, incompatible with eating food.

Researchers set out to find what would really happen if Americans were muddle-headed and sheep-like enough to actually try to reduce their sodium intake to 1500 mg/day. They discovered that, “the 2010 Dietary Guidelines for sodium were incompatible with potassium guidelines and with nutritionally adequate diets, even after reducing the sodium content of all US foods by 10%.”  Way to go, Guidelines

While these researchers suggested that a feasibility study (this is a scientifical term for “reality check”) should precede the issuing of dietary guidelines to the public, I have a different suggestion.

How about we just stop with the whole 30-year-long dietary experiment to prevent chronic disease by telling Americans what not to eat? I hate to be the one to point this out, but it doesn’t seem to be working out all that well.  It’s hard to keep assuming that the AHA and the USDA/HHS mean well when, if you look at it for what it is, they are willing to continue to jeopardize the health of Americans just so they don’t have to admit that they might have been wrong about a few things.  I suppose if a Consistent Public Health Message means anything, it means never having to say you’re sorry for 30 years-worth of lousy dietary advice.

Marion Nestle has noted that, up until now, “every single committee that has dealt with this question [of sodium-reduction] says, ‘We really need to lower the sodium in the food supply.’ Now either every single committee that has ever dealt with this issue is delusional, which I find hard to believe—I mean they can’t all be making this up—[or] there must be a clinical or rational basis for the unanimity of these decisions.”

Weeeell, I got some bad news for you, Marion. Believe it. They have been delusional. They are making this up. And no, apparently there is no clinical or rational basis for the unanimity of these decisions.

But, thanks to the IOM report, perhaps we can no longer consider these decisions to be unanimous.

Praise the lard and pass the salt.

Read ’em and weep:  The Reader’s Digest Condensed Version of the science from the IOM report.  Studies marked with an asterix (*) are studies that were available to the 2010 Dietary Guidelines Advisory Committee.  

Studies that looked at Cardiovascular Disease, Stroke, and Mortality

*Cohen et al. (2006)

When intakes of sodium less than 2300 mg per day were compared to intakes greater than 2300 mg per day, the “lower sodium intake was statistically significantly associated with increased risk of all-cause mortality.”

*Cohen et al. (2008)

When a fully-adjusted (for confounders) model was used, “there was a statistically significant higher risk of CVD mortality with the lowest vs. the highest quartile of sodium intake.”

Gardener et al. (2012)

Risk of stroke was positively related to sodium intake when comparing the highest levels of intake to the lowest levels of intake. There was no statistically significant increase in risk for those consuming between 1500 and 4000 mg of sodium per day.

*Larsson et al. (2008)

“The analyses found no significant association between dietary sodium intake and risk of any stroke subtype.”

*Nagata et al. (2004)

“Among men, a 2.3-fold increased risk of stroke mortality was associated with the highest tertile of sodium intake.” That sounds bad, but the average sodium intake in the high-risk group was 6613 mg per day. The lowest risk group had an average intake of 4070 mg per day. “Thus, the average sodium intake in the US would be within the lowest tertile of this study.”

Stolarz-Skrzypek at al. (2011)

“Overall, the authors found that lower sodium intake was associated with higher CVD mortality.”

Takachi et al. (2010)

The authors found “a significant positive association between sodium consumption at the highest compared to the lowest quintile and risk of stroke.” As with the Nagata (2004) study, this sounds bad, but the average sodium intake in the high-risk group was 6844 mg per day. The lowest risk group had an average intake of 3084 mg per day. “Thus, the average sodium intake in the US would be close to the lowest quintile of this study.”

*Umesawa et al. (2008)

“The authors found an association between greater dietary sodium intake and greater mortality from total stroke, ischemic stroke, and total CVD.” However, as with the Nagata and the Takchi studies (above), lower quintiles—in this case, quintiles one and two—would be comparable to average US intake.

Yang et al. (2011)

Higher usual sodium intake was found to be associated with all-cause mortality, but not cardiovascular disease mortality or ischemic heart disease mortality. “However, the finding that correction for regression dilution increased the effect on all-cause mortality, but not on CVD mortality, is inconsistent with the theoretical causal pathway.”  In other words, high sodium intake might be bad for health, but not because it raises blood pressure and leads to heart disease.

Studies in Populations 51 Years of Age or Older

*Geleijnse et al. (2007)

“This study found no significant difference between urinary sodium level and risk of CVD mortality or all-cause mortality.” Relative risk was lowest in the medium intake group, with an average estimated intake of 2, 415 mg/day.

Other

“Five of the nine reported studies in the general population listed above also analyzed the data on health outcomes by age and found no interaction (Cohen et al., 2006, 2008; Cook et al., 2007; Gardener et al., 2012; Yang et al., 2011).”

Studies in Populations with Chronic Kidney Disease

Dong et al. (2010)

“The authors found that the lowest sodium intake was associated with increased mortality risk.”

Heerspink et al. (2012)

“Results from this study suggest that ARBs were more effective at decreasing CKD progression and CVD when sodium intake was in the lowest tertile” which had an estimated average sodium intake of about 2783 mg/day.

Studies on Populations with Cardiovascular Disease

Costa et al. (2012)

“Dietary sodium intake was estimated from a 62-itemvalidated FFQ. . . . Significant correlations were found between sodium intake and percentage of fat and calories in daily intake. . . . Overall, for the first 30 days and up to 4 years afterward, total mortality was significantly associated with high sodium intake.”

Kono et al. (2011)

“Cumulative risk analysis found that a salt intake of greater than the median of 4,000 mg of sodium) was associated with higher stroke recurrence rate. Univariate analysis of lifestyle management also found that poor lifestyle, defined by both high salt intake and low physical activity, was significantly associated with stroke recurrence.

O’Donnell et al. (2011)

“For the composite outcome, multivariate analysis found a U-shaped relationship between 24-hour urine sodium and the composite outcome of CVD death, MI, stroke, and hospitalization for CHF.” In other words, both higher (>7,000 mg per day estimated intake) and lower (<2,990 mg per day estimated intake) intakes of sodium were associated with increased risk of heart disease and mortality.

Studies on Populations with Prehypertension

*Cook et al. (2007)

In a randomized trial comparing a low sodium intervention with usual intake, lower sodium intake did not significantly decrease risk of mortality or heart disease events.

*Cook et al. (2009)

No significant increase in risk of adverse cardiovascular outcomes was associated with increased sodium excretions levels.

Other

“Several other studies discussed in this chapter analyzed data on health outcomes by blood pressure and found no statistical interactions (Cohen et al., 2006, 2008; Gardener et al., 2012; O’Donnell et al., 2011; Yang et al., 2011).”

Studies on Populations with Diabetes

Ekinci et al. (2011)

Higher sodium intakes were associated with decreased risk of all-cause mortality and heart disease mortality.

Tikellis et al. (2013)

“Adjusted multivariate regression analysis found urinary sodium excretion was associated with incident CVD, with increased risk at both the highest [> 4,401 mg/day] and lowest [<2,346 mg/day] urine sodium excretion levels. When analyzed as independent outcomes, no significant associations were found between urinary sodium excretion and new CVD or stroke after adjustment for other risk factors.”

Other

“Two other studies discussed in this chapter analyzed the data on health outcomes by diabetes prevalence and found no interaction (Cohen et al., 2006; O’Donnell et al., 2011).”

Studies in Populations with Congestive Heart Failure

Arcand et al. (2011)

High sodium intake levels (≥2,800 mg per day) were significantly associated with acute decompensated heart failure, all-cause hospitalization, and mortality.

Lennie et al. (2011)

“Results for event-free survival at a urinary sodium of ≥3,000 mg per day varied by the severity of patient symptoms.” In people with less severe symptoms, sodium intake greater than 3,000 mg per day was correlated with a lower disease incidence compared to those with a sodium intake less than 3,000 mg per day. Conversely, people with more severe symptoms who had a sodium intake greater than 3,000 mg per day had a higher disease incidence than those with sodium intakes less than 3,000 mg per day.

Parrinello et al. (2009)

“During the 12 months of follow-up, participants receiving the restricted sodium diet [1840 mg/day] had a greater number of hospital readmissions and higher mortality compared to those on the modestly restricted diet [2760 mg/day].”

*Paterna et al. (2008)

The lower sodium intake group [1840 mg/day] experienced a significantly higher number of hospital readmissions compared to the normal sodium intake group [2760 mg/day].

*Paterna et al. (2009)

A significant association was found between the low sodium intake [1,840 mg per day]) and hospital readmissions. The group with normal sodium diet [2760 mg/day] also had fewer deaths compared to all groups receiving a low-sodium diet combined.

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

Adele Hite, PhD MPH RD 33 Comments

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.

The Mobius Strip of Policy Change

Adele Hite, PhD MPH RD 2 Comments


I love working with individuals, but it takes policy-level change to really make an impact on public health. Policy, however, is a double-edged sword. Decades-long cascades of unintended consequences can arise from well-intentioned policy. The Dietary Guidelines started out in 1980 as an unmandated humble little 40-page booklet offering nutrition guidance to the public, while freely admitting that “we don’t know enough about nutrition to identify an “ideal” diet for each individual” and that “in those chronic conditions where diet may be important . . . the roles of specific nutrients have not been defined.”

Since then, I’m still not sure how, the Dietary Guidelines have become the center of all information and decision-making surrounding food and nutrition in America—in policy, healthcare, industry, media, and science (where researchers should know better than to use a policy document as the basis for scientific research). And—for better or worse—Americans have actually shifted their eating habits to fall in line with Guidelines recommendations (see: Americans don’t follow the Guidelines—or do they?)


The Guidelines were created to prevent chronic disease.  They have changed very little in 30 years, while rates of obesity, diabetes, and other chronic disease have rapidly increased (see: Public Health Nutrition’s Epic Fail). Currently, there is no “policy lever” for changing the way the Guidelines are created or administered. The Guidelines have no system of checks and balances, no outcome evaluation process, and no way to counter the influence of entrenched special interests (including both the food and science industries).

Right now, it seems that no amount of public outcry, accumulation of scientific evidence otherwise, or increase in diseases the Guidelines were meant to prevent can shift them from their current staked position that a high-carbohydrate, high-fiber, low-fat, low-cholesterol, low-saturated fat, low-sodium diet is right for all Americans. Under the USDA/HHS “calories in, calories out” paradigm, it’s Americans that need to change (“eat less and move more”), not nutrition policy. Policy changes are urged only to “make the healthy choice the easy choice”  for fat stupid Americans (especially low-income ones) who apparently otherwise don’t care and can’t think.

I would expect such policy reform to have, as Jon Stewart put it, “the draconian government overreach we all love with the probable lack of results we expect.”

So what kind of policy reform should we be working towards? One of the Big Questions I ponder is whether we need to replace the current USDA/HHS Dietary Guidelines with “better” ones, or find a different way to create nutrition policy, or just ditch all government-sanctioned nutritional recommendations altogether. (Other Big Questions: What’s for dinner? and How can I further embarrass my children?)

I don’t fundamentally oppose or support government-funded nutrition programs. If they were administered differently, I might like them a lot more. If we are going to use government funds to feed people, we will need some way of guiding that process. Right now, our federally-funded nutrition programs have a tendency to serve as outlets for cheap industrialized food, and I’m afraid that our nutrition guidance has not only allowed, but encouraged that role. On the other hand, scrapping that guidance altogether may leave government programs that are struggling for funds vulnerable to choosing food from the lowest bidder, which would only serve to reinforce the current situation.

I also have problems with replacing one-size-fits-all Guidelines with different one-size-fits-all Guidelines because that process denies the very real variability in nutritional needs and preferences of individuals and diverse sub-populations. Worse yet, it teaches people that answers about nutrition come from packages and experts rather than the body’s response to food.

As a transition, or middle ground, I currently favor the idea of locally-determined nutritional policies and programs. Sounds good, right? Nutrition programs could be tailored to meet the needs of the community they serve.

But this is where the confluence of things needed to make this type of policy shift happen turns into a Dilbert cartoon. Everything that needs to happen requires something else to happen first until it all loops back on itself like a Mobius strip.


Let’s take school lunches.  

Ideally, the type of school lunches served should be determined by the members of the community eating them, i.e. the kids, parents, teachers, etc.  This allows for appropriate community-level health, ethnic, cultural, regional, seasonal, and economic adjustments and prevent fiascos like the Los Angeles lunchroom garbage cans filled with “healthy” lunches (like “brown rice cutlets”).

Ideally, a trained professional at the local level, for instance an RD, would be able to guide this process, balancing the nutritional needs of that specific community with other social and cultural factors, creating an affordable menu, and modifying the program based on outcomes.  But this would mean that the RD would have to have training across the spectrum of nutrition science, rather just following USDA/HHS policy statements which are based on research done on white (frequently male) adults circa 1970-1980 and which may not be applicable to other populations.

This in turn would require the nutrition curriculum for health professionals to not be skewed by entrenched interests in academics, politics, and industry (and would probably require almost a complete re-thinking of 30 years of nutrition epidemiology).

This would require the USDA/HHS and other institutions to support–through funding, publication, and use—nutrition research that may possibly undermine or even contradict 30 years of previous nutritional guidance. This research would not only provide a knowledge base for health professionals, but would provide an unbiased source of information for consumers which would help to create informed stakeholders in the nutrition-food system.

At the same time, industry, producers, and growers would have to work with the community to make foods available that meet the demands of the local program at a reasonable cost.  And right now—due to agricultural practices and USDA policies—foods that are widely and cheaply available to federal nutrition programs are the ones that the USDA/HHS Guidelines have determined are “healthy” even though this definition of “healthy” seems to be based, at least in part, on whether or not those foods are widely and cheaply available for federal nutrition programs.

See what I mean?  I have a hard time figuring out where we need to insert the monkey-wrench that will stop the endless cogs from turning out the same policies, practices, and programs that have been radically unsuccessful for the past 30 years.

Which won’t, of course, stop me from trying.

As I’ve been working with Healthy Nation Coalition and tossing ideas around with people who are also working on this issue, I’ve found some that I believe are fundamental to fixing our food-health system. These concepts originated with people much smarter than me, but I am hoping that in my academic work and in our non-profit work at Healthy Nation Coalition, I will have the opportunity to be a part of developing them further:

1) N of 1 Nutrition – a movement towards more individualized nutrition, although the “1” can also be a family, community, or other subpopulation

2) Nutritional Literacy – a movement to foster an understanding of the cultural forces that shape our nutritional beliefs and our relationships to food and food communities

3) Open Nutrition – a movement to raise awareness regarding the laws, policies, institutions, and other social, economic and cultural forces that may impact access to nutrition information and development of sustainable systems that produce foods that support health

It takes about 30 years for any given scientific paradigm to shift. It is time. But how will we do it differently? I think these concepts are the “next steps” that will help us steer the next 30 years of nutrition in a direction that may help us avoid another cascade of unintended consequences down the road. More on each soon.


If Nutrition Experts Built Bridges–

Adele Hite, PhD MPH RD 10 Comments

If you are an engineer, your plan—bottom line, no fudging about—has to WORK. All. The. Time. It’s what we expect from engineers.

On the other hand, if you are a Government-Approved Nutrition Expert, your plan doesn’t have to work AT ALL.

Which may be why we don’t let Nutrition Experts build bridges.

To ensure a more impressive rate of success, engineers tend to build their bridges and elevators based on a few mysterious but fundamental concepts like physics (or as we say around here, fweezix). Now, to paraphrase Barbie, I understand that physics is TOUGH. But it is also, well, insurmountably the real deal, and anything that defies the laws of physics is generally—for lack of a better word—considered to be magic.

Now, from my biochemistry classes, it looks like the principles of nutrition are built on chemistry, and the principles of chemistry are built on—you guessed it!—politics physics But when I step across the hall to my public health classes, then the principles of nutrition are based on the Dietary Guidelines, which—as they tend to be in defiance of the laws of physics—I guess must be magic!

Despite the rockin’ groove, I’m not sure that I believe in magic.

But Calories In = Calories out is not magic, it’s physics, right? It seems indisputable—a veritable law of thermodynamics—that if you consume fewer calories than you expend, you will lose weight. Conversely, if you consume more calories than you expend, you will gain weight. Duh.

Sometimes when things aren’t working (i.e. major bridge oopie ), we get a glimpse of the realities of the physics behind the system. Let’s take a look at a category of individuals that do lose weight easily—too easily: Type 1 diabetics. A type 1 diabetic could eat 5000 calories a day, never move a muscle, and still lose weight (for the record: this is not a good thing). What happens to those calories? Why don’t they get stored as fat (hello? calories IN?) A type 1 diabetic can’t store them as fat. Why not? No insulin. Without insulin, the body cannot store energy at all. Type I diabetics must be given insulin or they literally waste away. It’s not because they try harder; it’s because of physics.

What this means is that it can’t just be the amount of calories that we are consuming, but also the source. And in the case of unnecessary carbohydrates in the diet, it’s likely to be both. The increase in caloric intake we’ve seen in the past 30 years has come almost entirely from industrialized carbohydrate food products—subsidized and endorsed by the USDA.

Would obesity rates have skyrocketed without the Guidelines prompting Americans to eat fewer animal products—especially meat and eggs which contain Very Scary saturated fat and cholesterol—and more whole grain cereal products? We’ll never know. But physics does tell us that carbohydrate foods have particular qualities that affect fat storage and metabolism, specifically: “A high carbohydrate meal stimulates the production of insulin. Insulin inhibits the body’s ability to use fat for energy and stimulates the uptake of fat and its storage as triacylglycerol” (Campbell & Farrell, 2009). That’s straight from my biochemistry textbook.

Now I don’t care if you eat carbs or not. Some of my best friends are carbs. But can we stop pretending that somehow—magically—there’s no relationship between the two figures above?

Apparently we can’t. According to many Nutrition Experts, including Marion Nestle, our low-fat Dietary Guidelines can be blamed only in that they do not do more to “address caloric intake, portion size, inactivity, and other contributors to obesity” (Woolf & Nestle, 2008). Notice that “caloric intake,” “portion size” and “inactivity” are all things that are our fault—in contrast to a diet recommendation of mostly carbohydrates, something the USDA and HHS are responsible for. In other words, if chubby little Americans can’t “achieve energy balance” by eating less and exercising more, it’s not because the Guidelines aren’t helping us, it’s because we are simply not trying hard enough.

(True Confession: I mostly just wanted to draw that cartoon.)

Should we reduce our calories? Maybe not a bad idea for some folks.

What kind of calories should we reduce? Ask an engineer. Unless you believe in magic . . .

References:

Campbell MK, Farrell SO. Biochemistry, 6th ed. United States: Thomson, 2009. p. 730.

Centers for Disease Control and Prevention (CDC). Trends in intake of energy and macronutrients–United States, 1971-2000. Morbidity and Mortality Weekly Report. 2004 Feb 6;53(4):80-2.

Woolf SH, Nestle M. Do dietary guidelines explain the obesity epidemic? American Journal of Preventive Medicine. 2008 Mar;34(3):263-5.