A Bad Thing

As a science, nutrition can be a little ... confusing (to say the least). I intend to address the reasons for some of this confusion later, but for now I want to write about some of the implications. Most, if not all people, have many ideas about what is and what isn't "healthy". Unfortunately, this is one of those situations where a little information, even if it is the right information, can be a bad thing.

For better or for worse, the landscape of food has been transformed into a jungle full of terrific and terrifying possibilities. We have both figuratively and literally deconstructed food into thousands of chemicals, added a few of our own, and re-assembled them in every way imaginable. Everyone has to eat, but there is simply too much information (and a paucity of evidence) to make an truly informed decision, so we simplify. We dichotomize foods and nutrients in our mind into 'good' and 'bad' based on what we know. I imagine it looks a little something like this:

It is all that any of us can really hope for in the vast and ever-changing food environment, but leaves us vulnerable to food advertising. Food companies are far more interested in your money than in your health. What's more, they are well equipped with a arsenal of impressive sounding nutrients that many consumers likely know little about (fatty acids like DHA, isoflavones like genistein, amino acid derivatives like HMB, and so on). Very few of these nutrients are actually required in the diet, but instead are endowed with drug-like properties and fanciful claims.

Our only shield against this onslaught is the government who have, quite regrettably, taken a pro-business, individual responsibility stance on the issue. The result - supermarkets are chock-a-block full of unhealthy products guised as being wholesome. Most are fairly innocuous such as our breakfast favorites (sugar-sweetened multivitamins with fiber), while others are downright alarming, acting as vehicles for the uncontrolled delivery of drugs. Sadly, the notion that the best products to avoid are those that appear healthy has some merit. A simple, yet elegant solution has been put forth by Michael Pollan:

"Eat food. Not too much. Mostly plants."

This view asks us to embrace ignorance and eat like our grandparents. It's a good premise. If we put aside the little that we know, we are far less susceptible to nutri-fluence. However, I think this ship has sailed. Food and nutrition information is all over the place, and it is not in our nature to ignore it. Furthermore, there isn't much actual food left in the supermarket, and many consumers lack the skills and/or motivation to prepare meals from scratch.

So what are our options. I doubt that we are anywhere close to having nutrition figured out, and I don't think that this successful advertising approach is going to stop anytime soon. All that we can do is make people consciously aware of this ruse so that they are less easily deceived. Perhaps with time, our population will shift from pre-contemplation to contemplation, and we can start to address some of these issues at their source.

Take Home Message:

The presence (good source of omega-3s) and/or absence (cholesterol-free) of single nutrients does not make a food healthy.

The YAM CanFoG Study - Design

If I take one thing away from my experience as a graduate student, it will be that the most important component of any study design is coming up with a catchy abbreviated title. Thus, I am pleased to introduce the Young Adult Male following Canada's Food Guide (YAM CanFoG) Study.

Now that this is out of the way, I am able to provide you with a description of the study itself. For those of you just tuning in, the idea for this study was developed by Eric Briere, a physical trainer that, having never looked at Eating Well with Canada's Food Guide, was disturbed by the number of servings of Fruits and Vegetables and Grain Products that it recommends he consume in a day (8-10 and 8 servings, respectively). For those interested, his video can be viewed here, and a detailed background on why I have decided to embark on a similar experiment can be found on my post entitled "Canada's Guide to Weight Gain?".

The YAM CanFoG study will look at the effect of following the Canadian food guide for one month on energy balance in a young man with low activity (me). To prepare for this, I designed a 7-day food cycle using meals and snacks that I would generally consume, which also adhered to Eating Well with Canada's Food Guide. I then conducted nutrient analysis on the diet using the USDA nutrient database to get an approximation of macronutrient and energy intake. The following table summarizes the analysis:

As you can see, this diet provides ~2000kcal/d with ~100g protein. This intake is below the 10th percentile (2100kcal/d) of estimated intake for my age / gender based on 500 simulated diets following Eating Well with Canada's Food Guide that were published in the paper describing the food guide development. The simulated diets were derived using data on dietary intake form the Federal-Provincial Food and Nutrient Survey from British Columbia, Manitoba and Ontario. One possible (and likely) reason for the discrepancy in my estimated energy intake is that I am choosing foods that are lower in added sugar and fat compared to the general population for which the simulated diets were derived. However, Canada's Food Guide does recommend that "limiting food and beverages that are high in calories, fat, sugar and salt", so my food choices adhere to the food guide well, even if they are atypical.

The primary outcome for this study will be change in body weight. Each week at the same time (Monday morning), I will be weighed using a calibrated electric scale in a blinded manner. I will be wearing the same clothing for the weigh in, and will have attempted to void prior to reduce sources of error. The average of two weights to the nearest 0.1 lbs will be taken a recoded. As a safety measure, weight gain or loss greater than 3 lbs half way through the experiment will be deemed as clinically significant and mark the end of the study.

A major confounding variable when using weight as a primary outcome is physical activity. To control for this, I will be wearing BodyBugg and maintaining a physical activity journal. I am aiming for the 30-60 minutes of physical activity per day during the study as recommended in Eating Well with Canada's Food Guide.

Subject Characteristics:

Age: 27

Gender: Male

Race: White

Height: 5'5"

Weight: ~140 lbs

Occupation: Student

Illness: No known illness

Drugs / Supplements: 4+ coffee / day

Diet Records:

For interest sake, please see tables below to gain an appreciation for the range in macronutrient and energy density of foods within the same food group. These are just for the foods that I am consuming in my 7-day meal plan - all are presented in a per serving according to Eating Well with Canada's Food Guide. Using a worst and best case scenario (and assuming that the subtext of the food guide are just polite suggestions), I could be consuming anywhere between 1,025 calories and 3,308 calories per day.

Thanks for your interest.

Canada's Guide to Weight Gain?

Will following Canada's Food Guide make you gain weight?

This is the question being asked by personal trainer Eric Briere, a question that he intends to put to the test over the next month. While his study design was not apparent from his short video, his hypothesis is clear - he will gain weight. His video has been receiving a fair amount of attention from the virtual community (>100 people Facebook "like" it), and I am concerned about the implications of his experiment.

Eating Well with Canada's Food Guide is an important resource for Canadians, providing basic information on the amount and types of food that should be consumed daily to meet nutrient needs and reduce the risk of certain chronic diseases. Given the dramatic increase in overweight and obesity over the last few decades, it is of the utmost importance that public health messaging be unambiguous and evidence-based. This can be difficult to achieve sometimes, which is understandably frustrating for the public who become increasingly cynical about public health recommendations. The issue of unclear, somewhat vague messages when it comes to dietary recommendations is an interesting one that is worthy of discussion. I will be sure to blog about this later, but for now, I just want you to think about your own diet. It is likely to vary considerably from one day to another, and to have changed over time. Are you able to clearly and accurately describe your lifetime exposure to food and nutrients?

Back to the matter at hand - did Health Canada overlook caloric intake when developing Canada's Food Guide? The answer is no. The paper describing the development of Eating Well with Canada's Food Guide can be found on Health Canada's website. The portion sizes and specific recommendations for each Food Group (ie. eat at least one dark green and one orange vegetable each day) were empirically-derived from Canadian data. The food intake patterns were assessed using 500 simulated diets for each age / gender group. The criteria for energy needs is described below.

"The median energy content of simulated diets should be at or below the Estimated Energy Requirement (EER) calculated for reference individuals using a sedentary level of activity. Measured heights and weights from the Canadian Community Health Survey, Cycle 2.2, were used to determine median height and median normal weight for each age and gender group. These were then used as inputs to the EER equations. A sedentary level of activity was considered most appropriate so that there was no overestimation of requirements."

For most age / gender groups, the median intake was within or below the median EER range with some exceptions (Males 71+, Females 9-13, 14-18, 51-70, 71+). Keep in mind, the median EER range was determined for sedentary persons, and would need to be multiplied by a physical activity coefficient to be compliant with the recommended physical activity levels of Eating Well with Canada's Food Guide (30-60 minutes per day for adults).

As an example, the median EER range for sedentary males 31-50 years old was 2250-2450kcal/d. To convert the EER to align with the recommendations for physical activity in Eating Well with Canada's Food Guide you must multiply the EER by a physical activity coefficient of 1.11. In this case, the range in median EER becomes 2498-2720kcal/d, which exceeds the 90th percentile of energy intake based on the simulated diets adhering to the food guide (2406kcal/d).

This being the said, you might ask yourself why I am worried about Eric Briere's experiment. Based on the data for 31-50 year old males, he is more likely to lose weight than gain it, right? The problem is that he may not be following Canada's Food Guide.

The food intake pattern that became Eating Well with Canada's Food Guide includes the within food group recommendations to "make each food guide serving count...". His suggestion that he will eat 10 bananas a day to meet his fruit and vegetable requirement does not adhere to the recommendation to "eat at least one dark green and one orange vegetable each day".

Moreover, with things like bananas, size matters. Given the diversity within foods like bananas and bagels (his other example), it is necessary to consider the actual amount to obtain an accurate estimate of servings. Portion distortion is common, and explains the misconception that it is difficult to meet daily requirements for Fruits and Vegetables and Grain Products.

That being said, it is certainly possible to adhere to the food guide and gain weight (particularly if you are trying to make that point). Emphasizing energy-dense foods like avocados and nuts within each food group and being sedentary would almost guarantee weight gain.

His study is interesting and has important implications, and I look forward to seeing the results. If his hypothesis is confirmed (he gains weight), it will indicate that we should re-evaluate the methodology used develop Canada's Food Guide, and its appropriateness for use as a public health resource. There is considerable measurement error, both in estimating energy expenditure and predicting energy intake for a population following a food guide, so his research question is a good one. To my knowledge, Eating Well with Canada's Food Guide has not been subject to a validation study in free-living subjects. However, if he does not comply with the food guide, consume his usual foods, and maintain his physical activity level, his study will not address his research question, and the message of weight gain that is conveyed to his clients and the viral community may do undeserved, irreparable damage.

For those of you that are also following his progress, I encourage you to read the paper explaining the development of Eating Well with Canada's Food Guide. For those interested, as I have been looking to conduct an n=1 study on myself, I will be repeating his experiment. Because I am biased, I am going to do my best to remove myself from the equation, and be as transparent as possible.

Using foods / meals that I regularly eat, I developed a 7-day food record and analyzed it using the USDA nutrient database. Throughout the month, I will record my physical activity, and weigh myself every Monday morning, wearing the same clothes, in a blinded manner (someone else will record my weight).

If you have any suggestions of how to further improve this study, please let me know as soon as possible so that I can incorporate them.

Thanks for your interest.

Katamay SW, Esslinger KA, Vigneault M, et al. Eating Well with Canada's Food Guide (2007): Development of the food intake pattern. Nutrition Reviews 2007; 65(4): 155-166.

Inception

It all starts with an idea.

"An idea. Resilient, highly contagious. Once an idea has taken hold of the brain it's almost impossible to eradicate."

- Dom Cobb (Inception)

The idea that obesity can be cured by dieting is a great example of inception. Not in the, Leonardo DiCaprio broke into your subconscious kind of way, but in the sense that the idea has been planted into your mind, and slowly becomes your own. For people raised in North America (and likely elsewhere), the inception begins at a very young age. While it is difficult to pinpoint exactly when it occurs, most 5 year-olds are familiar with dieting for weight loss, the extent of which appears to be related to maternal dieting practices (1). The idea is nurtured with constant reinforcement from our environment, and allowed to develop deep roots, becoming a belief. This presents a problem.

"I think it's better to have ideas. You can change an idea. Changing a belief is trickier. Life should be malleable and progressive; working from idea to idea permits that. Beliefs anchor you to certain points and limit growth; new ideas can't generate. Life becomes stagnant."

- Rufus, the 13th Apostle (Dogma)

The common belief that obesity can be cured by dieting is a problem because it has other implications.

• It implies that there is something wrong with the diets of obese people (for the most part, I agree). However, along with this comes the fallacy that normal weight individuals must therefore have good diets. Importantly, this misconception is not limited to diet - take a look at Homer Simpson for an example of how we view obese people (D'Oh!, Mmmm..., Woo hoo!). This is also the foundation of weight bias, one of the few prejudices that remains socially acceptable today.

• It implies that the cause of obesity is modifiable behaviors. In a superficial sense, I agree. The connection is simple enough to follow - obesity is the storage of excess calories as fat that results from prolonged period of consuming more calories (eating) than you expend (exercising), both modifiable behaviors. This simplistic view of obesity is the basis for the eat-less, move-more approach to its prevention and treatment (seems to be working well so far). This attitude further stigmatizes obese individuals, this time implying that their failure to do anything about their weight reflects a lack of will power.

I would argue that this bleak view of obese people is collective ignorance, and needs to be addressed before we can or will do anything to address the current obesity epidemic. Unfortunately, people can't easily be persuaded to change a belief, a sobering truth that I have come to appreciate in my attempts convince people that the eat-less, move-more paradigm is destined to fail. My efforts, while largely unsuccessful, have not been fruitless. I have learned much about the epistemology (way of knowing) and justifications for this belief, leading me to the concept of inception.

While I would like to blame TV shows like "The Biggest Loser" and convincing testimonials of guaranteed, quick and easy weight-loss diets for planting the idea, it is just as likely that it came from health authorities doing their best to spread the eat-less, move-more message. This view is so pervasive in our society that most people take for granted that it is a fact. Once indoctrinated, our perceptions of reality are skewed to reinforce the belief. Obese people are on our radar, and when we see them buying fast food, or chowing down on a bag of chips, it reaffirms what we know. Add to this the fact that everyone knows someone who has lost weight, and we have all the evidence we need to justify our current view of obesity and obese people.

Before going further, I would like to acknowledge that obesity is related to individual behaviors. There is no doubt that weight-loss is achievable under controlled circumstances. However, this does not mean that obesity is caused by individual behaviors - a small, but important distinction. My rationale for such a seemingly contradictory statement is that I believe that our behaviors are the conduit through which our environment causes obesity, an idea that I will elaborate on in future posts. For now, I would like challenge some of the assumptions related to the eat-less, move-more paradigm.

Dieting is an effective treatment for obesity. Depends on your perspective of effective. I would hardly call a treatment with a success rate of less than 5% effective. These odds are likely to conflict with our own experience (perception) of dieting success (can you name 19 people who failed at dieting for every 1 person that succeeded). What is more concerning is the potential consequences of a failed diet attempt in the other 95% (depression, rebound weight gain).

Obese people have worse diets (and lifestyles) than thin people. A widely-held belief for which the evidence is relatively weak and inconsistent. Take a study of 5,890 Canadian adolescents (11-16yo) for example (2).

% of normal, overweight and obese subjects not consuming F & V daily:

Fruits 64%, 71%, 68% (boys) 58%, 62%, 59% (girls)

Vegetables 61%, 67%, 61% (boys) 53%, 59%, 52% (girls)

% of normal, overweight and obese subjects consuming unhealthy foods daily:

Soft Drinks 27%, 31%, 36% (boys) 17%, 16%, 21% (girls)

Sweets 26%, 20%, 20% (boys) 24%, 18%, 20% (girls)

Potato Chips 12%, 10%, 11% (boys) 7%, 4%, 7% (girls)

Cakes/Pastries 6%, 7%, 10% (boys) 4%, 2%, 6% (girls)

The authors note that it is possible that the failure to find a consistent trend may be due to the fact that "overweight and obese individuals are more likely than normal weight individuals to misreport food intake". I wanted to be sure to acknowledge this possibility, but emphasize that the fact still remains that normal weight individuals have nothing to brag about.

Obese people don't lose weight because they are unmotivated and/or lack will power. I highly doubt this to be the case. Given our attitudes towards obesity and open bias towards obese people, I believe that there is incredible impetus to be thin in our society. The multi-billion dollar industry is proof enough that we are motivated to lose weight. Unfortunately, biology is not on our side - there are powerful mechanisms (leptin deficiency) that are working on both energy intake and expenditure to counteract weight loss attempts (more on this to come).

To be clear, I am not suggesting that obesity is unrelated to lifestyle, or that obese individuals are not liable for their actions. Nor would I argue that we should cease and desist all public health efforts to promote healthy eating and physical activity. What I am proposing is that we adopt a more sensitive and sensible view of obesity as a disease. This is a condition that has serious physical and psychological complications, and we have limited tools for managing it. The argument that people with obesity are somehow reaping what they sow undermines our ability to address the root causes of the condition, and perpetuates the cycle of inception. To overcome this, we need to cast aside this stereotype and see the world through unbiased eyes (best to start with a mirror). Keep in mind, when you point your finger at someone else, there are 3 more fingers pointing back at you.

1. Abramovitz BA, Birch LL. Five-year-old girls' ideas about dieting are predicted by their mothers' dieting. JADA 2000; 100(10): 1157-63.

2. Janssen I, Katzmarzyk PT, Boyce WF, et al. Overweight and obesity in Canadian adolescents and their associations with dietary habits and physical activity patterns. Journal of Adolescent Health 2004; 35: 360-7.