Simplistic Nutrition Recommendations: Unintended Consequences

Maureen Bligh, MA, RDJanuary 20, 2010

Outline Background Recent research on consumer

attitude & behaviors Role of food grouping system Role of nutrient-rich foods Nutrition education application tips Summary and action steps

Background: Common Simple Messages

Clean your plate

No Pain No Gain

A sun tan is a sign of good health

Starve a cold, feed a fever

If a little is good, then

more is better

Background: Common Messages

Eat more fruits and veggies

Avoid fat and sugar

Use sunscreen

Limit your fat intake

Exercise!

N Engl J Med. 1997 Apr 17;336(16):1117-24.

Examples of simplistic recommendations and outcomes Dietary Guidelines “Choose Low-fat

foods”▪ Gave unintended permission to

consume more low- fat foods which are not always lower in calories

1971 - 2000▪ % kcal/fat reduced▪ Total kcal increased▪ Total gm fat increased

Examples of simplistic recommendations and outcomes (cont.) Weight loss diet Bone

loss Vegetarian Nutrient

deficiencies Low-carb Nutrient

deficiencies and chronic disease

Sugar Avoid some nutrient-rich foods

Am J Clin Nutr 2007 Apr;85(4):972-80 www.dairycouncilofca.org/PDFs/Unintended-consequences.pdf

More examples Diabetic kids may focus too much on

carb counting▪ December Diabetes Care

Consumers Stress over Organic Eating ▪ Blog post on eatright.org

Other examples?

Foods versus SupplementsUnintended consequences can also result from

overuse of supplements: Overdosing on single nutrients Nutrient deficiencies secondary to

imbalanced ratio of supplemental nutrients Overlooking non-nutritive components in

foods

JADA 2005:105(8):1300-1311

Possible outcomes of nutrition legislation and regulations

Legislated solutions for school food service and school vending

Banning or limiting certain foods perception that those foods should always be avoided e.g. pizza, flavored milk

Allowed foods diet soda, engineered donuts and toaster

pastries; are these “healthy”?

Nutrition and You: Trends 2008 67% of consumers said diet, nutrition

and physical activity are “very important” to them personally.

40% of people strongly agreed with the statement: I actively seek information about nutrition and healthy eating

www.eatright.org/trends2008

Nutrition and You: Trends 2008 The most popular sources of food and

nutrition information were TV (63%) and magazines (45%), followed by the internet.

Dietitians, nutritionists, doctors and nurses were ranked as the most credible

www.eatright.org/trends2008

Nutrition and You: Trends 2008 54% of people think there are foods that

they should never eat. 38% strongly agree that they are always

hearing information about what NOT to eat, rather than what they SHOULD eat.

www.eatright.org/trends2008

International Food & Information Council Consumer Survey

>60% believe that certain foods and beverages can provide multiple health benefits

>80% say they are consuming, or would be interested in consuming, foods and/or beverages for such benefits.

http://www.ific.org/research/foodandhealthsurvey.cfm

Food Guidance Systems:Old-school tools can still solve new-

age problems

History of USDA’s Food Guidance

1940s

1950s-1960s

1970s

1992

2005

Food for Young

Children

1916

Guiding Principles— Unchanged

Overall Health

Up-to-Date Research

Total Diet

Useful Realistic

Flexible Practical

Evolutionary

MyPyramid Recommendations Compared to Consumption

-100

0

100

200

Perc

ent c

hang

e

Females 31-50 Males 31-50

Increases

Current Intake

Decreases

Fruits Vegetables Grains Meat & Beans Milk

Bars show percent change needed in consumption to meet recommendations

Diets skewing food-grouping approachSimplified diets are often based on limiting or

omitting foods from a certain food group to reduce calorie intakes

Low-carb diets limit breads, grains & cereals and fruit group

Vegetarian diets reduce intake from meat, beans and nut group, and sometimes dairy group

High protein diets increase intake from meat, beans and nut group, to the possible detriment of intake from other groups

Many diets limit or omit dairy based on the false presumption that dairy foods are fattening.

Unintended consequences of limiting food groupsDiet Nutrient

implicationsPossible long-term

health consequences

Low dairy Low in calcium, magnesium, potassium, riboflavin, Vit B6, B12, A, D

FracturesOsteoporosis Higher risk of hyper-tension & colon cancer

Low carb Low in whole grains, fiber, B-vitamins, folate

Heart diseaseConstipationDiverticulosis Neural tube defects

High protein Low in carbohydrates, fiberHigh in saturated fat

Heart diseaseDiabetesStrokeCancer

Choose nutrient-rich foods from all food groupsThe nutrient-rich food categories are aligned with

the Dietary Guideline's definition of a "healthy diet" and MyPyramid's five food groups, and include:

Brightly colored fruits and 100% fruit juices Vibrantly colored vegetables and potatoes Whole, fortified and fiber-rich grain foods Low-fat and fat-free milk, cheese and yogurt Lean meat, poultry, fish, eggs, beans and nuts

Nutrient-Rich Foods Coalition Partnership that brings together leading

scientific researchers, communications experts and agricultural commodities

Dedicated to advancing scientific and market research to develop tools to help people understand and incorporate nutrient-dense foods into their healthy lifestyle.

Supports the 2005 Dietary Guidelines for Americans and MyPyramid

www.nutrientrichfoods.org

NRFC website Recipes and meal ideas Navigating the grocery

store Nutrient-rich shopping list Guide to nutrition labels Portion control basics Adding nutrients to meals Eating out Fitting in “fun” foods

www.nutrientrichfoods.org

New considerations: Front of Package (FOP) Labeling

Front of Package (FOP) LabelingPros

▪ Consumers want a simple, easy to use system and quick guidance.

▪ Ease of comparing similar food products (e.g. cereals, snack foods)

Front of Package (FOP) Labeling

Cons▪ Systems encourage good food – bad

food perceptions among consumers▪ Does not allow for individualization▪ Some nutrient-rich foods may

receive low ratings e.g. nuts, cheese, meats.

What to look for in a FOP label?Is the scoring or program-nutrient criteria: Publicly available or published in scientific

journals? Objective and balanced between positive and

negative nutrients? Scientifically representative of consensus

dietary guidance—2005 Dietary Guidelines for Americans and MyPyramid

Is it flexible to accommodate changes anticipated with the 2010 revision of the Dietary Guidelines?

What to look for in a FOP label? Are there additional program support tools

such as websites, in-store cooking classes, tours, and other education programs to help consumers understand the use of specific foods in planning meals and in the total diet?

Can the program information be transferred to other settings when food choices are made outside the supermarket?

Optimal Diet

Genetics &Ethnicity

Preferences,Aversions,

Intolerances

Social,Cultural,

Religious Factors

Lifestyle &Environmental

Factors

Smoking

Age & Gender

Disease risk

Activity level

Individualizing nutrition advice

Individualization in nutrition advice: Role of health professionals

Help clients prioritize their health goals Identify specific and realistic measures to

accomplish those goals Use the food guide system as the basis for

forming a sustainable, healthy eating plan▪ Flexible enough to accommodate a wide range

of goals and health concerns▪ Ensures adequate intake of individual nutrients

Total Diet ApproachFocus on…… Instead of…. Total intake of foods Emphasis on nutrientsDietary patterns, e.g. MyPyramid or DASH Diet

Single-foods approach

Healthy diet over time Good versus bad foodsHealthy eating pattern + supplements

Over-reliance on supplements

Goals of Nutrition Education To encourage a balanced, individualized

diet that includes adequate amounts and variety of foods from all food groups

To dispel the “good” and “bad” foods perspective

To discourage extreme dietary restrictions

Small steps that lead to long-term compliance

Venues for Nutrition Education

Need to embrace new venues to reach today’s consumer:

Internet Websites Listservs Electronic newsletters Wellness centers

Application Tips for the Practicing Health Professional Look at the ‘big picture’ of dietary

advice; Strike the right balance between info overload and simplicity

Include recommendations for all food groups – with action steps for priority issues

Encourage foods first

Application Tips (cont) Take an individualized approach to

health Consider how to reach a broad range

of consumers with balanced dietary messages

Give them more credit; don’t “under-sell” clients with nutrition information

Application Tips (cont) Embrace newer research and

knowledge once validated Be open to shifting paradigms &

pass that along to clients.

Actionable Recommendations Avoid vague

recommendations such as “Eat less salt”

More specific is better – determine cooking skills, food preferences to develop specific action plan

Develop plan that will make most difference

Case Study Case study: 70 year old women, 5’5” and

weighs 165 lbs. She has type 2 diabetes. She is on “diet only” therapy and has been told in the past by her doctor to cut out sweets and eat more fruits and vegetables. After 6 months her weight is essentially unchanged and her hemoglobin A1C is about the same. Her doctor starts her on oral diabetes medication and she is referred to a dietitian.

What are the possible unintended consequences of the dietary advice given to this woman?

What was missing in the doctor’s initial treatment plan? Diet History: caloric intake is adequate to maintain her current weight. She has cut out sweets as her doctor instructed but consumes several glasses of fruit juice per day. You also discover her vegetable and dairy intake is low.

Resources

These tools can help you get the right balance between nutrition complexity and accuracy:

MyPyramid Menu Planner MyPyramid Food Tracking Worksheets Eat Smart. Play Hard. Healthy Lifestyle Personal Nutrition Planner

Resources (cont.)Nutrition and You: Trends 2008. ADA

www.eatright.org/trends2008

2008 Food and Health Survey: Consumer Attitudes toward Food, Nutrition & Health (IFIC). http://www.ific.org/research/foodandhealthsurvey.cfm

Summary Simplistic dietary recommendations can

easily lead to unintended health consequences.

Before adopting dietary change, examine the overall impact it will have, particularly on long-term health and wellness.

A food grouping system such as MyPyramid should form the basis for a balanced diet that can be sustained over the long term.

Choosing nutrient-dense foods from all food groups is the best way to optimize nutrient intakes while keeping calorie intake in check.