Calories | Bonnie Modugno, MS, RD

Choose Less, Weigh Less

November 29, 2012 by Bonnie

The Los Angeles County Department of Health has blitzed the LA region with billboards and bus advertisements extolling people to eat less. The ad campaign caught my attention last week the day before Thanksgiving. So timely.

The ad campaign is obviously getting our collective attention. Steve Lopez of the LA Times penned his thoughts in today’s column. The ad campaign is being funded by a 1 million dollar grant funded by the Centers for Disease Control in the name of “…something has to be done” (a quote by LA County’s Public Health Director, Johnathon Fielding that I plucked from Lopez’s piece).

Yet, there is ample evidence that research doesn’t show any link between nutritional awareness and one’s waistline. The truth is that knowledge doesn’t readily translate into behavior. Why is LA County Health Department spending $1M on this campaign?

THE COSTS OF POOR METABOLIC HEALTH ARE REAL

Obesity–and more specifically, poor metabolic health–is likely to cripple us. Economic costs are ballooning and it is not just the cost of health care. The cost to business is also enormous. Unhealthy people are less productive, take more sick time, use more medical care, and drive up health insurance premiums.

Teenagers who are diagnosed with type II diabetes today are just as likely to develop kidney failure as previous generations, eventually living their life on dialysis or on a transplant list. Except they will be in their 30′s and 40′s –not their 60′s and 70′s. Who is going to be healthy enough to work?

IS “DOING SOMETHING” ENOUGH?

The general panic in public health and medical communities regarding “the obesity crises” can lead to wishful thinking. We are a knowledge based society and health care is a knowledge driven discipline. It is easy to get stuck in the illusion that knowledge is the solution (ie: if we tell people what they should eat, they will.)

It is true that eating less for some people will result in weight loss. But it is also true that most people who struggle with their weight already know this. Knowledge is not the problem. The real challenge is translating knowledge into behavior.

“Sound bite nutrition” tends to exaggerate the benefits of any simplistic solution. It sounds so easy, “just do it.” But if it was that easy, people would. True change takes readiness, willingness, and ability. Knowing what you should do is merely a component of ability. Telling people what they should do without addressing why they can’t or don’t do it often just creates guilt, shame and/or depression.

WHY PEOPLE CAN’T OR DON’T EAT LESS

To be truly effective, the entire health care community needs to appreciate factors contributing to the challenge for any one person. Then that person deserves the support and resources to figure out an approach to eating that works.

The solution is a public health nightmare. But it is disingenuous to pretend that eating less can be accomplished without addressing why people eat more. There are many factors influencing the capacity to self regulate as well as the biological mechanisms that regulate hunger, satiety and energy metabolism, including:

An environment that encourages indulgence and celebrates the extremes
A culture that pretends more is always better, or that there is never enough.
An abundant and adulterated food supply
A farm and food policy that subsidizes extremely refined and processed foods, making them the easy and cheaper choice
FDA policy that continues to confer GRAS status to problematic ingredients like trans fats
A culture that celebrates stress junkies and the sense that you can (or should) be willing to manipulate your body to accomplish whatever is expected
A modus operandi that values money more than our environment, time, energy, or any other resource
EPA’s chemical management policy that allows thousands of chemicals that are known endocrine disruptors and persistent organic pollutants to be spewed into our environment. 95% of these agents enter our bodies via the food chain and interfere with glucose tolerance and thyroid function.
A GNP that gives no value to traditional “women’s work” which means there is no value for the time, energy, skill or resources needed to prepare food and eat well
A work environment in which too many people are unwilling or unable to take time off or work reasonable hours

We live in a society that is constantly bombarded with pressure to do more and be more. A chronic level of stress leads to all kinds of maladaptive behavior, including craving sweet and overeating. We have no time to teach our children how to survive abundance, but we do teach them how to cope with ever more destructive behaviors. As the bar of expectation raises higher, more and more people struggle. We are literally creating mental illness as well as a whole host of conditions linked to poor metabolic health.

CALORIES COUNT, BUT THEY ARE NOT THE ONLY THING THAT COUNTS

In the mix, public health authorities tell us to eat less. We are told to count calories. We are increasingly disassociated from our bodies in a quest to meet someone’s idea of what we should be eating.

Those of us working in the trenches need to be more honest. There is no one right way to eat. Eating less doesn’t always lead to healthy weight loss. A lower BMI doesn’t not guarantee good health. Thin people don’t necessarily eat healthier than heavier people. Thin people diet of heart disease, diabetes, cancer and a host of other maladies. Truth be told, we should stop hyper focusing on obesity and we need to tone down the rhetoric regarding calories. After all, if weight loss was a mere math problem, some very intelligent people would have solved it by now.

Filed Under: Blog Tagged With: addiction, calories, cancer, coping, diabetes, eat less, endocrine disruptors, heart disease, hunger, metabolism, obesity, public health, satiety, self regulatation, Steve Lopez, stress, weight loss

BEYOND CALORIES: Why the ratio of carbohydrate, protein and fat counts, too

November 11, 2012 by Bonnie

I have a client I am seeing currently that embodies why it can be important to discern what balance of carbohydrate, protein and fat works better for any one person. I have worked with hundreds, if not thousands, of clients with similar outcomes. But to listen to many nutrition experts, calorie counting is king. Not so fast.

A TRUNCATED CASE HISTORY

MB is a 40 something married woman with two children, Asian American descent. She eats mostly whole foods, vegetables and beans with small amount of animal protein. Exercises regularly. Splurges occasionally with wine, bread and cheese with girlfriends and a few sweets, but that didn’t use to be a problem. Gained 10 pounds over the last few years. Not happy.

MB showed me weeks of tracking intake on MyFitnessPal. Carbohydrate intake ranged 55-70%, but was especially high in the morning. Calorie intake ranged 1200-2000 per day.

We chatted about what was important to her and what changes made sense. MM shifted to more protein, less carbohydrates–especially in the mornings. In one month, she lost 4.25 pounds. She measures about 2.5 inches less at her waist and 1.5 inches less at her hips. She is shopping in her closet and wearing pants that she had given up on.

MM reports that food finally makes sense to her. She understands why she feels bloated after eating more carbohydrate than she can handle. She is currently navigating her cultural holidays without gaining weight. She anticipates refocusing her efforts once the festivities are over next month.

THERE IS MORE TO WEIGHT LOSS THAN COUNTING CALORIES

When someone’s diet is abysmal, eating more whole foods and fewer calories will always make a positive impact. These changes are important, but they are the easy call. What happened to MM is not unusual. There are many people who do “everything right” and still gain weight or can’t lose weight that they want to lose. Often people slip up because they feel hungry or at least not content. It is too hard to be constantly fighting the sense, “I need something.”

Eating more protein in the morning with Greek yogurt, berries, nuts and a sprinkling of granola

I focus on hunger and satiety. Calorie counting rarely does. My more insulin resistant clients often find that an adequate intake of protein and fat with moderated carbohydrate intake enhances satiety–that sense that you are satisfied after eating– and minimizes overeating at night. They crave less sugar and/or other refined carbohydrates. These are core reasons they are able to eat less and lose fat weight. I like to think they are learning to work with their body.

Many calorie counting proponents forget or maybe just don’t pay enough attention to many other factors that influence energy metabolism. Calories count, they just aren’t the only thing that counts. I recently heard scientists report that the global obesity epidemic can no longer be explained by energy intake. Endocrine disruptors, sleep debt, use of psychoactive agents and other factors influence how our body uses energy.

BEYOND CALORIES

Despite all the diet chatter, it is important to remember that there is not one single right way to eat. The critical goal for each of us is to figure out the approach to food that works.

Filed Under: Blog Tagged With: Asian Indian, belly fat, breakfast, calories, carbohydrate, counting calories, diet, endocrine disruptors, food, hunger, inches, insulin resistance, metabolic syndrome, night eating, protein, psychoactive drugs, satiety, sleep debt, weight loss

HEALTH HALOS: What happens when people assume what healthy means?

October 29, 2012 by Bonnie

Health halos convince a naive public that certain food is healthy, other food isn’t. The halo even gets extended to places: grocery stores, restaurants, even someones own kitchen. You hear things like “she cooks healthy food” or “they serve healthy food” despite the fact that most locations also serve or sell food that is not inherently healthy. In addition it is certainly possible to eat a mix of healthy foods that is not healthy for you, and therein lies the problem with health halos in the first place.

A recent article in Bloomberg Businessweek is an example of misguided use of health halos. Mike Roberts is the CEO of a new restaurant concept, and is to be commended. The Lyfe restaurant menu embraces the new world of local and sustainable food. Bravo. The problem is how this effort is contrasted with his former life as an executive at McDonald’s and the food served at McDonald’s.

FOOD OF THE FUTURE: LOCAL AND SUSTAINABLE

Local and sustainable are primarily environmental issues with some health implications. Less carbon footprint, food grown in a way that minimizes use of pesticides or other man made chemicals, food grown with no artificial fertilizers that can create dead zones in oceans are all good things for the planet. Ultimately, having fewer endocrine disrupters in our environment and a more sustainable food supply is definitely better for us.

When the writer describes Lyfe’s menu as local and sustainable it is inferred that this must mean it is healthier. It is also interesting that the writer would like to press the compare/contrast button with McDonald’s. To his credit, the former McDonald’s executive deftly sidesteps the issue.

WHAT IS “HEALTHY”?

It would take a more nuanced conversation to determine whether food at Lyte Kitchen is “healthier”. Just because something is low in calories doesn’t inherently make it “healthier”, just as frying a food doesn’t inherently make it bad for you. Unfortunately, the health care community and the media have created a monster. Sound bite nutrition–whether practiced in a medical setting or in journalism–has created a very distorted understanding of food, nutrition, and what it means to eat well.

First, Americans clearly have a peculiar notion of calories. You would think Calories are toxic and to be avoided if possible. Calories are energy. It is easy to forget that we need enough.

Second, vegetables are not inherently “healthier” than dairy, fish, fruit or beef in the same way that concrete is not inherently better than wood or steel. You want the right mix of materials no matter what you are building. The notion that a quinoa wrap is healthier than a hamburger is debatable.

WHEN A COMPLETE PROTEIN IS NOT MUCH PROTEIN

Let’s look at that Quinoa wrap a bit closer. Quinoa is the rare grain that is considered a complete protein, but most of the calories come from carbohydrate. My guess is that Lyfe kitchen chefs put quinoa in a grain based wrap with lots of veggies. Beautiful. But most of the calories are going to be from carbohydrate. I know many of my clients that would not feel satisfied, would have trouble managing their blood sugar or would feel the discomfort of bloating when they eat this way. So would I. Different people have different nutrient needs and that leads to my last point.

Too often people talk about a healthy diet as if it is a definitive thing. You can eat whole foods, close to the earth, and still not be eating a healthy diet for you. The media is fixated on the concept of best. Which is the best fruit? What is the healthiest vegetable? What is the healthiest diet? Most people–even the professionals that should know better–talk about good food and bad food. These are ridiculous conversations. They are asking the wrong questions. The goal is to figure out an approach to food that works for you.

REINFORCING STEREOTYPES

The writer is determined to differentiate the food at Lyte as “healthy” compared to McDonald’s food. Yet, the article talks about all the ways fruits and vegetables have found themselves on the menu at McDonald’s. The truth is that there is not one right way to eat. Enough fruits and vegetables is a good thing, but let’s not assume too much. I have seen many unhealthy clients eating only fruits and vegetables.

After years of being browbeaten with the message that fast food is bad, people assume that there is nothing healthy to eat at fast food restaurants. This notion is perpetuated by too many in public health and the medical community. It is a simplistic notion that is just plain wrong. All you have to do is scan what is sold in supermarkets and the calorie counts at sit down restaurants to know that poor food choices can be made everywhere food is sold. Even at Lyfe restaurant there are choices that one would consider indulgent, no matter how locally sourced and sustainably grown. Despite what the pundits say, more than where you eat, what matters is what you eat when you get there.

FAT BIAS: The most destructive stereotype of all

There is great harm from all the good food/bad food conversation. All you have to do is read the comments at the bottom of this article to see the evidence. The good food/bad food conversation quickly deteriorates into a fat bias slam fest. Too many very opinionated people want to believe that thin people eat healthy food and if you are overweight it is because you spend all your days eating all the wrong food. The ignorance is astounding. Too many people have not received the memo that it is possible to be healthy at every size (HAES).

In the end, this article is all about food and the direction we all need to move. Every entity that connects with food, farming and the public will need to come to terms with the destructive ways of how we conventionally produce our food. Every player will need to step up and change what they can. Have you figured out a healthy approach to food for yourself?

Filed Under: Blog Tagged With: calories, dead zones, endocrine disrupters, fat bias, fried food, fruits, HAES, health halo, healthy, local food, Lyfe restaurant, McDonalds, Mike Roberts, quinoa, soil ecology, sustainable, vegetables

Anti-obesity Ads: Help or Hindrance?

October 16, 2012 by Bonnie

Anti-obesity advocates are turning up the heat. Anti-obesity ads are on the airwaves and posted on you tube. The spots are compelling–and chilling. They target parents. They target junk foods. They are not honest.

Blue Cross and Blue Shield are behind the ads in Minnesota. Children’s Healthcare of Atlanta promotes different ads in Georgia. The UK and Australia have their own versions. All of the ads reinforce the belief that obesity is a math problem. Eat less, exercise more, and just stop buying all those unhealthy foods.

THE ANTI-OBESITY ADS LIE

While the ads may be thought provoking to some, others find them shaming and judgmental. I find them dishonest. Why only target overweight? Not everyone who eats poorly is overweight. Not everyone who is overweight eats poorly. You can be fit and fat. You can be skinny and sick.

Research tells us that obesity is much more complex than a simple equation. Calories do count. But they are not the only thing that counts. The issues are complicated by a myriad of forces. Genetics, food subsidies that influence food costs, food access, food storage and safety issues, as well as the time, energy and skill to cook more healthful meals.

There are even bigger issues. We live with an abundant and adulterated food supply. Food technology has done its best to deliver a food supply that is too tasty and appealing. Our overly refined food supply influences biological regulators that lead to overeating. And as one of the ads painfully illustrates, too many people use food to soothe, cajole and bribe. Doing the easy, quick or convenient thing has cultivated a population with less than adequate self regulation and resilience.

MORE THAN FOOD

And there are big questions looming about the role of endocrine disruptors (ED) and other persistent organic pollutants (POPs) that contaminate our environment and obesity. These agents influence the very hormonal processes that regulate how our body uses energy.

Many pesticides interfere with estrogen receptors. Estrogen plays an important role in fat metabolism. I don’t think it is coincidental that the growing incidence of obesity parallels the chemically driven green revolution and plastics industry. Yet these industries spew the very ED and POPs that are detected in our air, water and soil and eventually in our food. They accumulate in the fat stores in our bodies and are linked with glucose intolerance (which can lead to diabetes), thyroid disease, cancer and host of other maladies.

REAL SOLUTIONS

So lets stop pretending that obesity is the issue. Lets stop pretending that only heavy people eat excessive amounts of refined starch, sugar and fat. Let’s stop pretending that judging and shaming people is an effective way to change behavior.

If the folks at Blue Cross/Blue Shield were really interested in helping people, I wonder if they would consider covering nutrition and lifestyle counseling–before someone is diagnosed with diabetes?

Filed Under: Blog Tagged With: advertisements, blue cross, blue shield, BMI, calories, cancer, child obesity, diabetes, endocrine disruptors, estrogen, exercise, food, food access, food subsidies, food technology, genetics, HAES, health, health at every size, metabolism, overweight, persistent organic pollutants, pesticides, public health, resilience, self regulation, skinny, thyroid

Do Overweight Kids Really Eat Less Than Thin Kids?

September 13, 2012 by Bonnie

Are obese children under reporting what they eat? Yoni Freedhoff, MD blasts a recently published study suggesting that obese children may even eat less than leaner peers. Is it really so preposterous that thinner kids may eat more than their obese counterparts?

To be fair, asking 7 and 10 year old children to report what they eat is probably even more unreliable than asking adults. The data isn’t good. But data I see shows that everyone under reports, at all points of the BMI spectrum.

My real concern here is that there is no consideration of other factors that influence what the body does with those calories. The scientific community should consider calorie intake, but needs to also look beyond calories. They need to consider the wider scope of factors that influence obesity in our children and everyone else.

A ROLE FOR INSULIN RESISTANCE

One of those issues is something we call “nutrient partitioning.” People who are more insulin resistant tend to preferentially store calories as fat.

Insulin resistant people secret more insulin in response to the same load of carbohydrate compared to insulin sensitive folks. This insulin surge drives fat accumulation, as if the body was taking advantage of the “harvest” and storing for winter. In one study published in 2011, it was the children with a lower BMI (and presumably the more insulin sensitive children) who reported eating more candy, more sugar, and more calories.

Another study published in 2009 showed a very different interesting response to the composition of the diet. Some kids (typically those with a lower BMI with much greater insulin sensitivity) ate a high carbohydrate breakfast and felt satisfied for hours. Kids with the higher BMI and higher insulin levels–eating the same breakfast– felt hungry in 30-60 minutes. Only when the heavier kids ate more protein in the morning, did they feel satisfied as long as their thinner counterparts.

When energy from breakfast preferentially gets stored as fat, blood sugar dives. That someone is going to feel hungry again–sometimes in as little as 30-60 minutes after eating a meal. At the same time, the elevated insulin levels literally block fat from being mobilized for fuel. No wonder insulin resistant types feel like it takes a herculean effort to lose a pound.

A ROLE FOR GUT MICROBES

Another explanation could be the role of the bacteria in our gut. Scientific reports suggest that thin people tend to house a different a ratio of beneficial bacteria in their gut compared to their heavier counterparts. Researchers suggest that the relative proportion of Bacteroidetes is decreased in obese people by comparison with lean people. Firmacutes are in higher proportion in heavier people.

In addition studies suggest that diet plays a significant role in which bacteria strain thrives. At one symposium, a researcher representing Hi Maize Resistant Starch pointed to refined carbohydrate in the American diet as a significant influence. With more resistant starch, the heavier individuals lost more weight.

A ROLE FOR ENDOCRINE DISRUPTORS

The topic getting the least attention is also probably the one that is the most overwhelming. We are polluting our environment with substances that interfere with normal metabolism. These agents are known as obesogens, endocrine disruptors (ED) and persistent organic pollutants (POPs) They disrupt thyroid function, compromise glucose tolerance and are linked to higher incidence of all kinds of metabolic disease, including diabetes, obesity, heart disease and even cancer.

As the the entire global population becomes more obese, it seems less and less likely that just calories and a refined Western diet is to blame. I have a hard time believing that even the extremely poor are eating “too much” fast food and junk, especially as leaner counterparts are eating the same thing.

TEASING OUT THE TRUTH

The tricky part is that not all people gain weight on refined carbohydrate intake. Not everyone feels hungrier after eating refined carbohydrate. And not all insulin resistant people are heavy.

All of these observations lead me to believe that relying on calorie counts to explain why some are fat and and some are thin is simplistic at best. I wonder when scientists and clinicians will openly appreciate how much we still don’t know and look beyond the calorie balance equation. It seems more blinded than ever to believe the answer to obesity is simply eat less, exercise more.

Filed Under: Blog Tagged With: bacteria, BMI, calories, child obesity, endocrine disruptors, energy, fat, insulin resistance, microbes, persistent organic pollutants, thin

Do “Americans Eat Too Damn Much”?

May 17, 2012 by Bonnie

David Lazarus recently wrote a diatribe scolding gluttonous Americans in the Los Angeles Times. The notion that Americans just “eat too damn much” is a popular screed. Experts weight in and determine that it is advertising and marketing to kids that is the problem. Others claim there is not enough exercise. Well yes, and no. The issue is far more complex than these solutions suggest. Here are a few thoughts I shared with Mr. Lazarus.

Dear David,

I am glad I read your column on a regular basis. You have written insightful pieces, made poignant arguments, and exposed many wrong doings. I trust you are an intelligent and thoughtful man, but your screed regarding obesity is absolutely off the rails. You faltered the minute you embraced weight as the problem and assumed that the calorie balance equation is all there is to understand about energy metabolism. You assume that if people are obese it is merely because they are too gluttonous for their own good. You couldn’t be more mistaken.

Ironically, those of us in the trenches as well as many researchers are beginning to recognize the many ways and reasons people gain fat weight preferentially. Calories are only one of many factors. There are fewer and fewer people invested in the simplistic belief that “eat less, exercise more” is the answer to the growing obesity epidemic. In fact, the people who are still believers tend to be those people who have little personal or hands on experience with weight management (and please take that literally—researchers who mostly crunch numbers and publish the articles don’t count. Talk to those of us who work with patients and clients on a one-to-one basis)

Most of my clients struggle mightily. Of course calories count, they just are not the only thing that counts. Far more impressive people than I have argued that the issue is multifaceted and very complex . These authors identify 10 putative factors that have at least the same potential to impact the obesity epidemic as the currently popular and repeated arguments re: marketing to kids and not enough exercise. Studies show that thinner children can eat more calories, sugar, refined starch, and fat than their heavier counterparts. Clearly, obesity is not merely a math problem.

In my own work, I notice significant lifestyle factors that influence energy metabolism and create an environment that makes it more difficult to utilize fat and glucose effectively for fuel.

Poor food composition and distribution
Poor food quality (often an economic issue—see Adam Drewnowski’s work for more details) that is subsidized by government farm policy. Highly refined starch, sugar and fat is far cheaper to purchase per 100 calories than fresh fruit, vegetables, and lean protein sources
A preoccupation with “safe” that destroys all bacteria, including healthy bacteria that can improve gut microbiota and immune function
A gut microbiome that is linked to greater fat synthesis secondary to poor food quality
Gut peptide secretion secondary to food intake and gut bacteria that seems to alter appetite regulation
Sleep deprivation and poor sleep hygiene that increases sugar cravings and alters appetite
Chronic pain and may other sources of stress that exacerbate insulin resistance secondary to excessive cortisol secretion (consider a society that keeps raising the bar, increasing expectations, evaporating a safety net, etc)
Long hours at work and extensive commute time that erode time and energy for physical activity; anxiety on the part of workers that if they don’t sacrifice their personal life, they will soon be out of a job
Preoccupation with (financial) success, both in school and work, that pushes aside quality of life factors
Little or no appreciation or time to adequately shop, prepare and eat whole foods. We pretend we can do it even with 10-12 hour days away from home
Poor nutrition status for women of childbearing age. We know that pre-pregnancy nutrition status and the intrauterine environment influences the offspring’s metabolic health. Babies born to mothers with gestational diabetes and other states of insulin resistance (including obesity) are much more likely to become diabetic and/or struggle with metabolism and suffer high rates of birth defects. About 50% of births are unplanned for both married women and unwed teens. This does not bode well.
Exposure to endocrine disruptors and other obesogens that influence glucose tolerance, thyroid function, and insulin sensitivity via the environment—especially secondary to plastics, pesticides, and other contaminants (95% of which reach us via our food supply)

In addition, there are fundamental societal and system issues that complicate people’s access to adequate nutrition care and support.

Little money, time or willingness to teach life skills (including cooking, shopping, menu planning, budgeting, etc) to students. Somehow the overworked parents are supposed to do it all.
Negligible resources for adequate nutrition education in K-12. It is not easier to eat well today. It was easier when all we had to worry about was getting enough. Most schools don’t teach nutrition, and if they do it is taught by someone who isn’t really educated about nutrition. The information ends up being dogmatic and rigid—not very effective. Maybe the instructor’s degree is in PE or health, biology or the like….not good enough.
Pretending primary care doctors and nurses can deliver effective nutrition counseling. Doctors don’t get much nutrition training and often demonstrate even less skill in counseling. Nurse’s get about one semester’s worth. Have you ever asked how many patients get referred to dietitians or qualified nutrition counselors even with legitimate diagnoses?
Medical nutrition therapy (MNT) is rarely covered except for diabetics and folks with renal disease. Even then, time and access to an RD is laughable. Diabetics are supposed to be effectively “managed” at one local institution with four 15 minute appointments a year. And we wonder why people are “non compliant” and “lost to follow-up”
Everyone with dyslipidemia (cholesterol problems), hypertension, inflammatory states like gout, asthma, and allergies, and even cancer is likely to have to pay for MNT out of pocket unless dietitians accept a fraction of usual billing costs (but this is nothing new—it’s just that I can’t see 8-10 people in an hour and do any good—that’s not counseling, it’s pretending that knowledge is the same as behavior and there is only one right way to eat)
Individuals struggling with obesity, disordered eating and outright eating disorders are likewise not typically covered unless they are seen within a medical setting with an MD on board. The medical model doesn’t work so well when it comes to nutrition counseling. Our process is much like the therapeutic model used by mental health practitioners.
The government’s latest position with new funding for covering obesity basically establishes the primary care MD as the gatekeeper and employer for all nutrition services. How ironic that as someone with 25 years of experience working with clients in my own practice I am now expected to have an MD set the protocol and standards for my practice. Currently I teach MD’s, nurse practitioners, physician assistants and other health providers how to effectively help patients regain metabolic health.

Despite all of this, obesity isn’t the real issue. Weight has never been an effective bio-marker for disease or surrogate for health. It is sloppy and lazy science/journalism/public policy that continues to perpetuate the myth. The real issue is metabolic health.

Filed Under: Blog Tagged With: appetite, calories, exercise, farm bill, food costs, gluttony, gut peptides, metabolism, obesity, weight

The Tyranny of Choice

October 18, 2011 by

November 15, 2010

I tend to celebrate the range of food choices in my community and forget that having choices is not always a blessing. Making choices requires that you have enough information, time and energy to make decisions. It is easy to forget that sometimes all that effort can feel overwhelming.

I recently was speaking to a group of young teenage mothers. I was ready to initiate a discussion on making better choices when one of the young women raised her hand. She sighed and then spoke. Her message was clear. She was tapped out between school, raising a child, homework, working on the weekends and all the trappings of managing a household in the adult world.

At the end of her story, she stated her truth. She doesn’t want so many choices. It is easier just to eat what is put in front of her.

TOO MANY CHOICES

It is tempting to dismiss this young mother’s diatribe as pitching an adolescent fit, but many adults are equally overwhelmed in the marketplace. I work with clients who refuse to enter a big box store or even the local supermarket chain stores. In 2009 the average number of items in a supermarket totaled 48, 500. That’s a lot of choices.

These clients find themselves far less overwhelmed at local neighborhood markets and specialty stores. Smaller chains like Trader Joe’s and Fresh and Easy Neighborhood Markets are popular options.

LIMITED CHOICES

Smaller stores offer a limited mix of items. There aren’t dozens of choices of each item, but that seems to be ok. The customers seem pretty satisfied with the choices they do have.

Stores can limit the kinds of products they offer. On Trader Joe’s website they proudly claim that they only sell quality products with natural ingredients:

• NO artificial flavors, colors or preservatives
• NO genetically modified ingredients
• NO MSG
• NO added Trans Fats

Fresh and Easy boasts neighborhood markets that focus on the consumer. A video on their website summarizes the Fresh and Easy mission: shopping that is simpler, fresher, and allows one’s budget to go further.

Fresh and Easy markets also tout an emphasis on quality. Each food department identifies limited food ingredients or food preparation practices. Efforts include bakery items without added trans fat, artificial colors or flavors; milk products from cows who have not been given rBST hormones, and responsibly sourced fish as well as pork grown without hormones.

WHAT ABOUT LIMITED QUANTITIES?

Americans like value, and often value means getting as much as possible for the lowest price. While McDonald’s discontinued “Super-sizing” years ago, the legacy of super sizing lives on. “Too many choices” refers to the quantity of items as well as the number of items.

Big box stores are huge perpetrators of more is better. Why buy 6 ice cream cones at $4.99 when you can buy 36 and save a few bucks?

My answer is simple. It’s probably better for most people to buy less. Too many people buy 36 and think eating six is not so bad. Looking at 30 still in the box triggers no more than a shrug. Having so many left over feels different than eating six and polishing off the entire box.

In the world of bigger is better we have created a distortion of how much is enough. No wonder Americans are shocked at 8 oz. glasses of soda and other beverages when they travel abroad. At too many stores and fast food establishments a medium serving is 32 ounces. At sit down restaurants the servings may be only 16-24 ounces, but possibly more of a problem with limitless refills.

WHY DO THEY SERVE EXTRA LARGE IN THE FIRST PLACE?

My son often struggles with quantity. He likes big. He eats with his eyes, and more always seems to taste more delicious. He has historically struggled with, “How much is enough?”

As he navigates these early teen years, the struggle has intensified. Other kids eat more snack foods and empty calories in a day than Noah can manage in a month, and he is the one with an elevated BMI. Just last week he cried out, “Why do they serve extra large in the first place?”

There are probably many reasons, none of them considering the current health and nutrition challenges of the day. At one of Noah’s favorite take out places, he used to sneak away and treat himself with an extra large shake for $7. At 38 calories an ounce, the 32 ounce serving provides about 1200 calories.

The company proudly advertises only 1 gram of fat per ounce (about 288 calories). My guess is that there is a very modest amount of protein. Sugar– both the natural sugar found in milk and a significant amount of added sugar– makes up the rest of the calories.

MORE IS NOT BETTER
Why do restaurants serve 1200 calorie shakes? Why are there 1400 calorie burgers? Why do restaurants offer 3000 calorie entrees?

Ironically, many of the highest calorie items are served at sit down restaurants, not just the fast food eateries that get most of the grief from public health authorities. Why do restaurants do this when health authorities consider escalating obesity and diabetes rates an epidemic?

Maybe more of us need to start asking hard questions. Maybe it’s time to grow up and realize that more is not better. Sometimes less is more.

Filed Under: Blog, Middle Tagged With: BMI, calories, choices, diabetes, fast food, Fresh and Easy, obesity, restaurants, supersizing, Trader Joe’s, value

Questioning 5 Nutrition Myths on Huffington Post

October 18, 2011 by

Nutrition misinformation is ubiquitous. Sometimes the misinformation is lack of deeper thinking. A recent Huffington Post entry by Kristin Kirkpatrick, MS, RD, LD, caught my eye for just that reason.

Ms. Kirkpatrick addresses 5 dissonant myths probably tied together since it’s Thanksgiving week. She addresses myths about carbohydrates, eating late at night, weight gain during the holidays, the nutrient value of fresh vs. frozen food and the five second rule about eating food after it has been dropped on the floor. Each of the discussions left me wanting. Here’s my take on each of them.

1. THE CARBOHYDRATE MYTH

In 2002, researchers analyzed the diets of over 10,000 Americans by categorizing them by their carbohydrate intake. They found that those who had the highest intake of carbohydrates had the lowest overall intake of calories and were more likely to be at a normal weight.

My first thought is, “How nice it is to be insulin sensitive.” People who enjoy insulin sensitivity can eat a higher carbohydrate diet, they don’t get sugar and carbohydrate cravings, and they don’t gain water or fat weight readily. Of course they are leaner and eat less.

One third of Americans are born relatively insulin resistant. Lifestyle factors can make this worse. There are many studies that show many people thrive on a lower carbohydrate intake, some showing remarkable differences in weight management depending on genetic predisposition. (See work by Chris Gardner)

Continuing to insist that carbohydrates aren’t bad is missing the point. The question for each of us is how much and what kind of carbohydrates work best to give us the energy and sense of well being we seek.

2. THE MYTH ABOUT EATING LATE AT NIGHT

A calorie is still a calorie whether it is 6:00 p.m. or 10:00 p.m. The main importance is how many calories you consume throughout the day.

A calorie is a calorie. But not all calories are treated the same in our body. Nutrient partitioning is a phenomena that determines if your food will be used for energy or stored as fat. People who are insulin resistant secrete more insulin in response to their food intake. Excessive insulin drives energy into fat stores. This often causes a rebound hypoglycemia, increasing hunger and cravings for carbohydrate.

In addition, sleep and food intake influence hormonal responses that impact your appetite. As explained by Susan Dopart, MS, RD, a higher carbohydrate diet without adequate protein tends to increase ghrelin levels and “grows the appetite.”

Calories count, but hormones are potent factors determining what happens after you eat those calories. Weight management is not merely a math problem. If it was, we would have solved it by now.

3. THE WEIGHT GAIN DURING THE HOLIDAYS MYTH

They found that the average weight gain from Thanksgiving to New Year’s was less than 1 pound (0.8lb)

One of the biggest mistakes science makes is reporting findings that lead people to believe that the average experience is everyone’s experience. This data would be much more useful if the researchers or the author discussed the range of weight gain.

On the same diet people have very different experiences. Dr. Gardner’s research shows just that. My guess is that the insulin sensitive people experience far less weight gain, if any, as they enjoy the treats of the season.

Insulin resistant folks enjoy a few sweets, start to gain, experience even more carbohydrate cravings, and are soon slipping and sliding through the rest of the holidays. These are the folks who bring up the average. They can readily gain 5, 10 pounds and more between Halloween and the New Year.

It works in reverse as well. Weight loss is almost always easier for insulin sensitive folks.

My husband and friend once rode over 500 miles in a fund raising bike ride. Both riders ate the same food for the entire week. Both ate mountains of pasta, bowls of rice and handfuls of cookies to fuel themselves over the miles. The insulin sensitive guy lost 2.5% body fat over the 7 days. My husband lost 0.5%.

In private practice for over 25 years, I continue to observe people with a ride range of metabolic responses to food. Each person is their own puzzle and deserves to develop an approach to food that works for them. The person who gains 5-10 pounds over the holidays needs different support and guidance than the person who gains little or nothing.

4. THE FRESH VS. FROZEN FOOD MYTH

In the winter, however, eating fresh means not only paying more, but perhaps getting fewer nutrients. That’s because during the winter months, many fresh produce options have to travel hundreds and sometimes even thousands of miles to reach the grocery store.

I mostly don’t have a problem with this content, except I live in Southern California and the Huffington Post is a national, if not global publication. It is curious to me that the writer would limit her comments to her experience in the Northeast.

I appreciate the challenge of fresh fruit and vegetables in the Northeast. I remember a favorite aunt who lived in the Hudson River Valley. She would often chatter excitedly about the opening of farmer’s markets in early June. It would give me pause. In Southern California, my farmer’s markets are open all year long.

The disconnect for me is the assumption that produce traveling thousands of miles has fewer nutrients. I don’t think the issues is miles as much as time since harvesting. I’ve spoken to supermarket produce workers in Los Angeles. Too many people don’t know that produce in supermarkets is often sold 7-10 days post harvest–even with the San Jouquin Valley just a few hundred miles away.

The nutrition issue is freshness, not distance. It is important to not confuse the issue of nutrients with other significant discussions like sustainability. In the end, I agree that frozen produce may be the best nutritional bet during winter months for many people.

5. THE MYTH OF THE FIVE SECOND RULE

They found that when a piece of bologna was picked up off the tile floor that over 99 percent of the bacterial cells from the floor were transferred to the bologna.

People hear the word bacteria and get scared. We are a bacteria phobic people. For decades science and medical thinking has hinged on the premise that bacteria is bad. I’m not so sure.

We need healthy bacteria to keep us protected from opportunistic pathological strains. There is much discussion in the health care community that what we are lacking is enough healthy bacteria in our soils, in our food, in our guts. Lack of healthy bacteria has been linked to increasing incidence of gastro-intestinal diseases, asthma and allergies, as well as poor immune systems.

Today pro-biotic and pre-biotic supplements are sold everywhere. We pay extra for these bacteria to be added to our food. Why not let ourselves eat food that is a little less sterile? The real issue isn’t whether there is or is not more bacteria on our food. We need to ask better questions. Is it harmful? Is it helpful?

We need to be honest about what bacteria to be concerned about. Most of the pathogenic bacteria linked to our food supply is associated with animal and human feces, open wounds, and spoiled food. I don’t know if the bacteria found on the floor matches this risk.

My guess is that the researches know and probably reported this data in their findings. I would find the discussion more significant if Ms. Kirkpatrick could have addressed what kind of bacteria they found and it’s relative risk profile.

Filed Under: Blog Tagged With: bacteria, calories, holiday eating, late night eating, myths, nutrients, nutrition, Susan Dopart, weight, weight gain

SPIN: The Misinformation of Sound Bite Nutrition

October 18, 2011 by

Stone Hearth Newsletters leads with a story titled, “We have no idea what, or how much, we are eating: new study” Click on the link and you are sent to a story in MedPage Today titled “Recipe for Healthy Eating Not Easy to Stick To” I would have never guessed they are reporting on the same story.

While Stone Heart’s title is basically sensationalistic and misleading, I find fault with both leads. Med Page today pretends that it’s author’s version of healthy eating is the only one. In addition, Med Page quotes a senior Consumer Reports Health editor who is obviously confused. Since when is dieting the same thing as healthy eating?

Nancy Metcalf, senior editor at Consumer Reports Health (CRH) said, “We were surprised to find that very few Americans weigh themselves and count calories, two strategies that can help dieters stay on track.” I wonder why editors at CRH think that people need to weight themselves or count calories to be healthy eaters.

COUNTING CALORIES, WEIGHING SELF NOT NECESSARILY HEALTHY BEHAVIORS

In over 25 years of private practice I have learned that restrained eaters and chronic dieters often count calories and weigh themselves every day. Most of my clients with eating disorders count calories and weigh themselves at least once a day. Neither behavior is necessarily a marker of health.

The researchers also asked people about other food behaviors. How many servings of fruit and vegetables was probably on of the more reliable indicators. About 58% report getting five or more servings of fruit and vegetables a day. That’s actually impressive. Years ago the average intake was 1.2 servings a day.

WHAT FOOD BEHAVIORS ARE HEALTHY?

The rest of the report summary takes an interesting spin. The report states that about half of the population isn’t careful about limiting unhealthy foods. The language of article is negative, disparaging that more people don’t follow a fairly narrow definition of healthy eating.

The MedPage article states “Just 54% of people surveyed said they watch how many sweets they eat every day or on most days, while 51% said they limit fats (my italics). Is that really so bad?

HOW MUCH SWEET IS TOO MUCH?

Sweets are not necessarily taboo. Eating a square of chocolate or cookie after a meal doesn’t negate the healthfulness of the meal. Without some sense of quantity and frequency, comments like this lead people to believe the goal is to eat no sweets. This kind of thinking is a sure fire set up for “what the hell effect.” Someone trying to be healthy may feel like they “blow it” by eating one cookie, only to give up in frustration and eat the entire box.

This is the difficult thing about trying to ascertain the nature of a healthy diet. Some people eat well while they continue to consume a variety of foods with added sugar each day. Others can’t get away with even a small sweet once a day. It is virtually impossible to set a “reasonable” limit that works for everyone without being unnecessarily restrictive for some and overly generous for others.

WHAT ABOUT DIETARY FAT?

Both the amount and types of dietary fat recommended to consumers are debated these days. Scientists, researchers, and clinicians alike are questioning the 40 year old mantra to reduce fat intake. Both Walter Willet, PhD of Harvard and Andrew Weil, MD currently question the decades old advice. In fact, both have stated that fats are not the problem here. They believe real issue is excessive sugar and refined starches.

In December, 2010, Gary Taubes published “Why We Get Fat”. It also refutes the low fat mantra, explaining how a high carbohydrate, low fat diet can increase the risk of obesity as well as incidence of diabetes, cardiovascular disease and other inflammatory states.

There is plenty of evidence that there is not one right or healthy way to eat. The sooner public health advocates, consumer groups, researchers and clinicians come to recognize the need for more sophisticated nutrition advice, the better. In the meantime, the world of soundbite nutrition continues to polarize and confuse consumers.

Someone moved the cheese. We can no longer be preoccupied with yesterday’s problem, trying to determine the specific nutrient parameters of a healthy diet. We need to move on to the challenges we face today. How can we help individual consumers figure out an approach to food that is right (healthy) for themselves? That is a much different, and a much more challenging, puzzle to solve.

Filed Under: Blog Tagged With: Andrew Wiel, calories, Consumer Reports, fat, Gary Taubes, Med Page, Stone Hearth Newsletter, sugar, Walter Willett, weight

Dueling Dietary Guidelines: The Weston Price Foundation challenges the USDA

October 18, 2011 by

March is National Nutrition Month. Recently both the USDA and Weston Price Foundation published dueling dietary guidelines.

People are confused about food. Too many studies, too many experts, and all sorts of contrary ideas are floated as evidence of the right way to eat. Makes me wonder if there is a single “right” way to eat that works for everyone.

The Weston Price Foundation (WPF) threw down the gauntlet on February 14, 2011, introducing “Healthy 4 Life” in direct competition with the recently released USDA 2010 Dietary Guidelines. Why are food recommendations so controversial?

WPF followers see significant harm in the current approach recommended by the committee who drafted the USDA guidelines. They are not the only ones heaping criticism on the latest rendition of the guidelines. Comments by Walter Willet and Marion Nestle charge that USDA guidelines are overly influenced by commercial and corporate interests. Both Drs. Nestle and Willet contend that food interests are very powerful in this country. They say it is all a matter of following the money.

USDA RECOMMENDATIONS FOCUS ON CALORIES AND NUTRIENT-DENSE FOODS

USDA opens with two over-arching concepts. The first is a statement about Calorie balance and sustaining a healthy weight, basically committee speak for too many Americans are fat and need to lose weight. WPF states that meeting energy needs with recommended whole foods eliminates the need to count calories and will naturally lead to a healthier weight.

Secondly USDA recommends focusing on consuming nutrient-dense foods and beverages. WPF also encourages eating nutrient dense food, but their Food 4 Health guide looks remarkably different than the USDA 2010 Dietary Guidelines. Both organizations herald experts in their respective disciplines. How do they come to such differing positions on something as basic as what we eat?

WHAT IS A NUTRIENT DENSE FOOD?

USDA tends to focus on nutrients and nutrition science. USDA is very quantitative and evidence based. The Weston Price Foundation hones in on the quality of the soil, methods of food production and food preparation.WPF reinforces the value of eating traditional foods in a traditional way, pointing out that the last 40 years of nutrient based science parallels alarming increases in lifestyle disease states and obesity in this country and the world.

Both groups encourage the consumption of fruits and vegetables. USDA presses for more fiber, WPF presses for eating whole foods, organically grown.

WPF encourages beans and legumes in the diet as a compliment to animal products. USDA Dietary Guidelines suggest eating beans and legumes as a healthy substitute for animal products, which they say contribute excessive fat, saturated fat and cholesterol to the diet.

WHAT ABOUT FAT AND SUGAR?

Beyond these basic concepts, the rest of the guidelines couldn’t be more disparate. The USDA Dietary Guidelines continue to admonish Americans to avoid saturated fat, cholesterol, sugar and salt. WPF disagrees with most of these positions, encouraging healthy fats like butter and whole milk from grass fed animals. Ironically, WPF’s position is most aligned with current scientific thinking. Both of the groups agree trans fat is a problem. Interestingly, the FDA (a co-regulator of the food supply) continues to allow trans fats GRAS status. This means that in the world of food additives it is “generally regarded as safe”.

Both groups discuss the problem of excessive sugars and refined starches, but WPF definitely has the stronger voice. The USDA guidelines still allow for 10% of Calories from refined sugar. The USDA guidelines encourage Americans to eat more fiber, but not enough is said about eating less refined starch. Again, FDA’s position does not help. The FDA allows high fructose corn syrup along with a growing list of alternative sweeteners GRAS status, despite significant research linking these substances to metabolic issues and health problems.

FOCUS ON NUTRIENTS LITTLE MORE THAN BIOCHEMICAL MANIPULATION

I respect the science behind the USDA Dietary Guidelines, but the focus on nutrients often misses the point of eating. The science is easily manipulated into reductionist sound bites. The focus on nutrients distracts attention from critical aspects of soil ecology, farming, and food production.

Consumers have been taught to be preoccupied with the nutrient label. They often miss the big picture as they are eating mostly packaged foods. I have clients who eat berries for antioxidants, eat cottage cheese for leucine, avoid meat because of saturated fat and cholesterol, and drink sodium ladened sports drinks while telling me how they avoid salt in the diet. This is not eating. It is little more than biochemical manipulation.

CELEBRATING WHOLE FOODS

There is much to celebrate with the whole foods approach of Healthy 4 Life, as outlined by the Weston Price Foundation. Likewise, an argument can be made that there is value in learning about the role of individual nutrients in foods as encouraged by the USDA Dietary Guidelines. A problem occurs when preoccupation with individual nutrients trumps the value of eating whole foods.

Given the polarized nature of these two different sets of recommendations, the enduring challenge for consumers will be to determine an approach to food that works. This is the public health nightmare. It may be that there is no one right way to eat. The question remains, what approach to food works for you?

Filed Under: Blog Tagged With: calories, cholesterol, Dietary Guidelines, eating, farming, fat, FDA, fiber, food, food label, food nutrient, fruit, health, high fructose corn syrup, Marion Nestle, public health, satruated fat, sodium, soil, starch, sugar, trans fat, USDA, vegetable, Walter Willet, weight, Weston Price Foundation

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Do “Americans Eat Too Damn Much”?

The Tyranny of Choice

Questioning 5 Nutrition Myths on Huffington Post

Dueling Dietary Guidelines: The Weston Price Foundation challenges the USDA

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