- Amy Sotis
Conflicting Nutritional Advice Leads to Discouragement
After my summary, I will be copying (with permission) a re-formatted article that is from CME course content by Gail Frank and Peggy Papathakis, geared toward nutritionists, dietitians, nurses, physicians and other health practitioners regarding the conflicting messages we have inadvertently given to patients by trying to simplify nutrition messages over the years. I believe any person seeking to better their health, lose weight, or gain nutrition knowledge can benefit from reading the course content summary. Here are a few main points and my own summarization in case you do not have time to read the whole thing:
1) Oversimplifying nutrition messages can lead to an unbalanced diet and one lacking in key macro and micro nutrients. For example, statements such as "eat a low-fat diet" have led many people to assume "fat is bad" and consequently miss out on a plethora of health benefits. Benefits from good fatty acids are reducing an inflammatory response in the body (which is what happens when you eat a high-sugar/simple carb diet), and promoting vitamin metabolism (i.e. you need some fat for the fat-soluble vitamins to be absorbed in the blood and metabolized). Additionally, as fat in food is replaced with simple carbohydrates, this causes blood sugar to spike and insulin resistance can set in over time leading to Type 2 Diabetes and obesity. There are of course "good fats" and "bad fats" and we need to be educated from a scientific perspective on which are which. Some good fats are nuts, avocado, coconut oil, olive oil, and some animal-product fats that are in the naturally occurring state in the meat.
2) Avoiding or limiting whole food groups (such as strictly following a "low-carb diet") can lead to a dieting habit where unhealthy cycles of restriction lead to feelings of depravation and longing to be "off the plan". Thus, this dieting cycle leads to the ever-common "addiction" to dieting resulting usually in discouragement to try to eat healthy at all. Low-carbohydrate diets, popular for their purported weight loss and glucose-regulatory effects, have been linked to suboptimal intakes of vegetables, fruit, vitamin C and fiber, and to a higher consumption of meat, cholesterol and total fat intakes. I don't believe that trying a diet plan is wrong but I know from experience that if you view your current view of eating as a form of weight punishment you will not stick with it in the long term. My overall goal of Luminaries is to get people to see healthy eating, cooking, and exercise patterns as a way of life, not a short-term fix.
3) Research is showing that Americans, by and large, really do care about their eating practices and habits, and a cognitive link between their health and their eating is there. The foods we eat, day in and day out, really do have the power to shape the course of our lives from a health standpoint. The question begs to be asked: "If people know this, though, why don't we eat better?" Part of this article is to show that although we think Americans are knowledgeable about healthy eating, there have been so many mixed, oversimplified messages throughout the years that the public is confused to a large extent about what really constitutes healthy eating. My goal of teaching on science-based nutrition, whether to businesses, churches, or on over-night retreats is to provide a sound basis for sustainable, inexpensive healthy eating that is also delicious and satisfying.
4) Vitamin and mineral requirements in the diet should come from food, not supplements. Yes its easy to pop a pill for a little extra nutrition “insurance,” but people may have the misperception that their diets do not matter as long as they take their supplements. You can't overdose on vitamins from food sources, but you can from pills. Over-supplementation of particular vitamins can result in competition for intestinal absorptive sites, over- or under-absorption of nutrients and, in extreme cases, physiological imbalances. Zinc, iron and calcium, for example, may compete for intestinal absorptive sites such that an inhibitory effect is seen if one nutrient is consumed in higher amounts than the others. Components such as phytonutrients, fiber, bioactive peptides and other non-nutritive factors in our foods are critical to optimal health and prevention of chronic disease, yet most of these components have not been packaged in supplement form
"Healthy food" in the Luminaries Retreat definition, is largely unprocessed, freshly prepared vegetables, meats, fruits, beans, dairy products, and some complex grains. One recent retreat lunch was steak fajitas with careful substitutions from a typical Mexican restaurant style of preparation but this doesn't mean it isn't delicious and satisfying. Its still "real food" with an abundance of taste, vitamins, minerals, amino acids, fatty acids, and fiber.
The following summarization by Luminaries Retreat, LLC is taken from the article “Unintended Consequences of Simplistic Dietary Recommendations: Good Advice Gone Awry?” by Gail Frank and Peggy Papathakis and references cited are from their original work published by Gannett Education. For brevity, some points in the article directed at health professionals is omitted.
Article content approved for reproduction by Gannett Education
“Unintended Consequences of Simplistic Dietary Recommendations: Good Advice Gone Awry?”
By Gail C. Frank, DrPH, RD, CHES, Professor of Nutrition
Director, Internship Program in Nutrition and Dietetics
California State University, Long Beach
Peggy Papathakis, PhD, RD
Associate Professor Food Science and Nutrition Department
Cal Poly State University, San Luis Obispo
How often do we hear nutrition advice oversimplified? Omit trans fats ... exercise more ... eat more fruits and vegetables ... avoid high-fructose corn syrup ... take your vitamins. Everywhere we turn, we hear simple dietary messages intended to improve health and well-being. Neighbors, friends, relatives and co-workers are adept
at becoming “experts” on a topic and readily share their perspectives and advice. Advertising and the media publish messages, often sensationalized and based on singular studies, advocating consumption (or avoidance) of certain dietary components to cure our ails. Physicians, in their haste, often prescribe overly simplistic dietary recommendations without looking at the bigger picture. Even public-health recommendations, for sake of simplicity, often focus on one “nutritional nugget” at a time. Often, consumers are confused, left with a convoluted view of what constitutes sound nutrition and a healthy diet. Trying to balance the plethora of singular nutrition messages offered through multiple communication venues, they lose focus on overall healthy eating. As nutrition professionals, we need to examine the outcomes of implementing simplified advice and assess the long-term, often unintended, effects these could have on health. Rather than simplistic messages, we need to provide individualized, comprehensive, yet feasible advice that promotes lifelong health and well-being.
Unintended consequences can be defined as “any intervention in a complex system that may or may not have the intended result, but will inevitably create unanticipated and often undesirable outcomes.” While many people feel that simple nutrition recommendations can do no harm, often this type of advice can be shortsighted and lead to unintended and unhealthful consequences if the end result is an unbalanced diet. Anecdotal evidence of this phenomenon abounds; the most strongly substantiated examples include:
• The low-fat messages directed at consumers during the 1980s and ‘90s, intended to help them lose or manage weight and reduce their risk of heart disease, actually had the opposite effect as consumers misunderstood “low fat” to mean “low calorie,” which resulted in over-consumption. Between 1971 and 2000, the percent of calories from fat ingested by Americans decreased, but total fat intake increased and overall caloric consumption increased by 22 percent in women (corresponding to an extra 335 calories per day) and 7 percent in men (168 calories per day).1 In addition, the simple dietary recommendation to consume only low-fat or non-fat foods may influence an individual to restrict his or her intake of nuts, fish, avocado or oils that contain generous amounts of essential fatty acids, important to the inflammatory response2 and brain development.3 Focus-group research has found that consumers lack a definitive understanding of dietary fats, with many overwhelmed and confused about the various types of fats.4
• Avoiding or limiting whole food groups—in an attempt to reduce fat intake, lose weight, avoid animal products or out of concerns for intolerance symptoms—may similarly result in short-term nutrient deficiencies and long-term health consequences. Deficiencies in calcium, often the result of suboptimal dairy consumption, can result in fractures in children5 and osteoporosis and osteomalacia in adults.6 In fact, intakes of calcium, magnesium, potassium, zinc, sodium, folate, thiamin, riboflavin and vitamins B-6, B-12, A, D and E have been shown to be higher as more dairy is consumed.7 Low-carbohydrate diets, popular for their purported weight loss and glucose-regulatory effects, have been linked to suboptimal intakes of vegetables, fruit, vitamin C and fiber, and to a higher consumption of meat, cholesterol and total fat intakes.8 Research shows that eating a diet rich in whole grains is associated with reduced risk of heart disease, certain types of cancer and type 2 diabetes, and may also help in weight management.9
• Weight-loss diets are beginning to be seen as a risk for weight gain. An analysis of 31 studies on dieting found that dieting is a consistent predictor of weight gain, with up to two-thirds of dieters regaining more weight than they lost.10 A prospective study in 17,000 children ages 9 – 14 years old found that dieting predicted binge-eating behavior and concluded that, "... in the long term, dieting to control weight is not only ineffective,
it may actually promote weight gain."11 Another study in teens found that dieters had twice the risk of becoming overweight compared to non-dieting teens.12
Well-intentioned initiatives can result in unintended consequences
Often, nutrition and health professionals do not realize the impact a public-health initiative may have on consumer perceptions. For example, banning certain foods on school campuses in an attempt to improve the diets of children and adolescents may convey the message that these foods are “bad” or “unhealthy.” For example, pizza might be perceived as unhealthy for its fat content and flavored milk for its high-fructose corn syrup—when, in fact, these nutrient-dense foods can be incorporated into a healthful eating plan. Such well-intended mandates send the message that foods containing no “negative components” are healthy— possibly resulting in consumer perceptions, for example, that diet soda is healthier than chocolate milk and trans fat-free crackers are healthier than nuts. Research on consumer perceptions resulting from such mandates— and implications on food choices—needs to be conducted to better formulate initiatives and policy with the desired effects.
Consumers show readiness for more comprehensive advice
It is important for health professionals to understand what issues are most important to consumers in order to create effective nutrition and food-safety communications that motivate consumers to implement behavioral change. The American Dietetic Association’s (ADA) most recent survey on attitudes, knowledge, beliefs and behaviors around food and dietary habits sheds some light on how consumers feel about food and dietary advice:13
• Approximately 67 percent of those surveyed said diet, nutrition and physical activity are “very important" to them personally.
• Consumers are information-savvy, with 40 percent of them strongly agreeing that they actively seek information about nutrition and healthy eating.
However, 38 percent strongly agree that they are always hearing information about what not to eat, rather than what they should eat.
Consumers also have the mindset that food holds a key role in promoting health.
According to research conducted by the International Food Information Council:14
• 60 percent or more of Americans somewhat or strongly believe that certain foods and beverages can provide multiple health benefits.
More than 80 percent say that they are currently consuming, or would be interested in consuming, foods and/or beverages for such benefits.
Unfortunately, the “good foods, bad foods” myth is still being propagated, with 54 percent of respondents saying that based on information they’ve heard, they strongly believe there are some foods that should never be eaten.13 This has increased since 2002, when 43 percent agreed with the statement. This dichotomous belief about foods is fueled directly by the increasingly common, simplistic nutrition messages on exclusion— versus inclusion and diversity—of food choices. Often, the more forbidden a food is, the more desirable it becomes to some consumers.
While the most popular sources of food and nutrition information were television, magazines and the Internet—media that lend themselves to sound-bite, simplified messages—the most credible sources were dietitians, nutritionists, doctors and nurses.13
Thus, the average consumer is extremely interested in health and nutrition information and in improving his or her health and that of his or her family. This consumer receptivity to food and nutrition information, along with the credibility the health professional has built with the public, provides a unique opportunity for the nutrition community to make positive changes in our nation’s eating practices.
Food-grouping system as the cornerstone to nutrition advice
For more than 100 years, USDA has provided consumers with dietary guidance using a food-grouping system.15 These systems are meant to distill complex dietary information into a simplified structure that can be easily remembered and implemented. The average consumer—young and old—is capable of remembering the serving requirements for five food groups, yet would have a great deal of difficulty remembering
the recommendation for each key nutrient listed in the Dietary Reference Intakes.16 The most recent food- grouping system—USDA’s MyPyramid,17 released in 2005—is complex in that it consolidates a large volume of science-based information applicable to meet a wide range of needs, yet is simple enough to be feasible and actionable.
Because the food groups are based on “key nutrients”— the milk group provides calcium, potassium, vitamins A, B12 and D; the fruit group provides vitamins A,
C and fiber; the vegetable group provides vitamin C, phytonutrients and fiber; the meats, beans and nuts group provides protein, iron and zinc; and the breads and cereals group provides fiber, B-vitamins, carbohydrates and iron—it is unwise to omit a whole food group from one’s diet.
Unfortunately, many popular diets are based on limiting or omitting whole food groups in overly simplistic attempts to reduce one’s calorie intake. These limitations may result in a deficiency of key nutrients in one’s diet, eventually leading to fractures, chronic disease or a myriad of other issues. It remains critically important to consume a variety of foods and adequate amounts from each of the five food groups. Each of the groups offers abundant variety to meet individual taste preferences as well as cultural, lifestyle and economic needs.
Nutrition education is key to balanced diets
Education is an integral component of translating simple or complex dietary messages into action to ensure that consumers make commensurate modifications to balance their diets and maintain adequate nutrient intakes.
In today’s environment, the time and opportunity for nutrition education is limited, yet creative ways can be found to extend advice that is actionable, balanced and avoids unintended and unhealthy consequences. Communicating messages through materials and interactive pieces on institutional websites, in group classes and via LISTSERVs or blogs can be effective. Materials developed and distributed through health care providers and worksite wellness centers can also reach a large number of clients and patients. Regardless of the venue, the focus is to promote a balanced, individualized diet that includes adequate amounts and varieties of foods from all food groups and that sustains health over the long term.
Nutritional individualization needs to be factored into any diet plan
Research on the importance of nutritional individualization is accumulating at a rapid pace. With this knowledge comes confusion, however, as consumers may be asking:
• How do I synthesize all this information, including nutrigenomics, lifestyle and disease risk, to optimize my health?
• If my neighbor is successful with a certain diet plan, will it work for me?
• Does everyone need to be on a low-sodium diet, or just those who are “salt sensitive”?
• If I am active, at a healthy weight and not at risk for heart disease, do I really need to worry about saturated and trans fats?
What specific types of fruits and vegetables are better for those at risk of cancer?
Today, criteria that consumers use to make food choices are broadening. Factors traditionally driving food- choice decisions, such as taste, convenience, price and nutritional value, continue to be paramount in the minds of most consumers.18 However, the mindset is shifting among some consumers to include sustainability issues19 such as the environment (organic, locally grown), production (antibiotic-free, hormone-free, GMO- free) and animal-welfare issues (wild, free range and line caught). The health professional needs to consider these environmental and social factors when helping clients prioritize their health goals and formulate food plans.
Foods reign over supplements
While it seems an easy solution to pop a pill for a little extra nutrition “insurance,” some consumers may rely too heavily on supplements to meet their nutritional needs, or have the misperception that their diets do not matter as long as they take their supplements.20
On the contrary, it is far superior to get the nutrients one needs from foods21 for a variety of reasons:
• Supplements, a concentrated source of nutrients that are often not chewed or consumed with other foodstuffs, pose a greater risk of toxicity than food sources of nutrients.22
• The ratio of nutrients required to maintain physiological functions is generally appropriate in foods but often imbalanced in supplements, resulting in competition for intestinal absorptive sites, over- or under-absorption of nutrients and, in extreme cases, physiological imbalances. Zinc, iron and calcium, for example, may compete for intestinal absorptive sites such that an inhibitory effect is seen if one nutrient is consumed in higher amounts than the others.23
• Components such as phytonutrients, fiber, bioactive peptides and other non-nutritive factors in our foods are critical to optimal health and prevention of chronic disease, yet most of these components have not been packaged in supplement form. Other important non-nutrients that are present in foods have yet to be identified.
Absent the pleasures and social aspects of eating, the individual may lose the importance of foods and eating in a healthful lifestyle.
Supplements can play an important role in a well- thought-out diet plan when, for example, an individual is not able to meet his or her requirement due to food allergy, intolerance, aversion or inability to ingest the needed amount. However, the basis for a healthful diet should remain whole foods in as close to their natural form as possible.
Call to Action
In today’s world of sound bites, magic bullets, immediate gratification and quick fixes, it is more important than ever that health professionals be the voice of reason
and sound science. Consumers need to understand that heeding overly simplistic, singular nuggets of nutrition advice that eliminate or trivialize entire food groups can do them harm. They need to look beyond the obvious, short-term benefits to the potential long-term health consequences that may arise from neglecting to consider all factors in their dietary choices.
Systems are being developed to simplify healthy food choices for the consumer by labeling foods as being more or less healthful. There are a number of different systems introduced by manufacturers, retailers and nonprofit groups, most of them weighing the positive (e.g., calcium, protein, vitamins) against the negative (fat, saturated fat, sodium) attributes of a food and resulting in a final average score for each product. For this reason, these systems can promote a mentality of “good food, bad food” rather than “all foods fit in moderation”—and encourage consumers to assess individual foods rather than intake over a whole day or several days. In addition, since there is no commonly accepted scoring algorithm for these systems, it is unfeasible to determine which one(s) most effectively measures the healthfulness of a food. Thus, while these systems can provide useful information to the consumer, they are not the sole solution to healthy eating.
Consumers need education on how to utilize these tools as but one factor in their food-choice decisions.
• Look at the total health aspect of the nutrition advice he or she is receiving, rather than focusing on the nutrient of interest. If dietary changes are made in one food group, how will it impact other selections? Are there commensurate dietary adjustments that need to take place to compensate?
• Discourage clients from omitting a food or whole food group from their diets. Such omissions may result in nutrition deficiencies. Consuming a variety of foods from each food group ensures adequate and sufficient intake of all nutrients.
• Encourage clients to obtain their nutrients from foods rather than supplements. Foods contain a number of other as-yet-undefined factors that act synergistically with each other to enhance absorption and utilization, as well as non-dietary factors like fiber and phytonutrients that play a poorly understood but critical role in our health.
Supplements are appropriate in certain cases when it is not feasible to obtain adequate amounts of specific nutrient(s) from food sources.
Factor clients’ readiness to change into any recommendations, assessing their motivators and barriers to dietary changes. Use client-centered counseling techniques such as open-ended questions, affirmation, reflection, enhancing self- efficacy, problem solving, summarizing, goal setting and focusing on what is important to them. These techniques will optimize their accountability and ownership of the solutions and, ultimately, long- term success.
Motivate clients to take an individualized approach to their health by helping them understand that a specific nutrient, supplement or food that allegedly assists with weight loss, reduces cholesterol levels or increases energy in their neighbor will not necessarily have the same effect on them.
Take into account individual goals, needs and personal preferences, including ethnic and cultural diversity, to develop a dietary plan appropriate to their needs.
• Consider alternative methods of reaching consumers with balanced dietary messages, such as health care newsletters, developing or posting materials online on LISTSERVs and blogs and holding group sessions if individual consultation is not financially possible for clients.
• Make a conscious effort to provide sound nutrition advice on social-networking forums such as Facebook, Twitter, blogs and LinkedIn. Consider that the majority of blogs have no sourcing, and empower yourself to challenge inaccurate, misleading or imbalanced information posted by others, adding your “voice of reason” to the dialogue.
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