Simplistic Nutrition Recommendations:  Unintended Consequences Maureen Bligh, MA, RD January 20, 2010
Outline <ul><li>Background </li></ul><ul><li>Recent research on consumer attitude & behaviors </li></ul><ul><li>Role of fo...
Background: Common Simple Messages <ul><li>Clean your plate </li></ul>No Pain  No Gain A sun tan is a sign  of good health...
Background: Common Messages Eat more fruits  and veggies Avoid fat  and sugar Use sunscreen Limit your  fat intake Exercis...
Examples of simplistic recommendations and outcomes <ul><li>Dietary Guidelines “Choose Low-fat foods” </li></ul><ul><ul><l...
Examples of simplistic recommendations and outcomes (cont.) <ul><li>Weight loss diet    Bone loss </li></ul><ul><li>Veget...
More examples <ul><li>Diabetic kids may focus too much on carb counting </li></ul><ul><ul><li>December Diabetes Care  </li...
Foods versus Supplements <ul><li>Unintended consequences can also result from overuse of supplements: </li></ul><ul><li>Ov...
Possible outcomes of nutrition legislation and regulations <ul><li>Legislated solutions for school food service and school...
Nutrition and You: Trends 2008 <ul><li>67% of consumers said diet, nutrition and physical activity are “very important” to...
Nutrition and You: Trends 2008 <ul><li>The most popular sources of food and nutrition information were TV (63%) and magazi...
Nutrition and You: Trends 2008 <ul><li>54% of people think there are foods that they should  never  eat. </li></ul><ul><li...
International Food & Information Council Consumer Survey <ul><li>>60% believe that certain foods and beverages can provide...
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 Evolution...
MyPyramid  Recommendations Compared to Consumption Increases Current Intake Decreases Fruits    Vegetables  Grains  Meat &...
Diets skewing food-grouping approach <ul><li>Simplified diets are often based on limiting or omitting foods from a certain...
Unintended consequences of limiting food groups Heart disease Diabetes Stroke Cancer  Low in carbohydrates,  fiber High in...
Choose nutrient-rich foods from all food groups <ul><li>The nutrient-rich food categories are aligned with the Dietary Gui...
Nutrient-Rich Foods Coalition <ul><li>Partnership that brings together leading scientific researchers, communications expe...
NRFC website <ul><li>Recipes and meal ideas  </li></ul><ul><li>Navigating the grocery store </li></ul><ul><li>Nutrient-ric...
New considerations:  Front of Package  (FOP) Labeling
Front of Package  (FOP) Labeling <ul><li>Pros </li></ul><ul><ul><li>Consumers want a simple, easy to use system and quick ...
Front of Package  (FOP) Labeling <ul><li>Cons </li></ul><ul><ul><li>Systems encourage good food – bad food perceptions amo...
What to look for in a FOP label? <ul><li>Is the scoring or program-nutrient criteria: </li></ul><ul><li>Publicly available...
What to look for in a FOP label? <ul><li>Are there additional program support tools such as websites, in-store cooking cla...
Optimal Diet Genetics & Ethnicity Preferences, Aversions, Intolerances Social, Cultural, Religious  Factors Lifestyle & En...
Individualization in nutrition advice:  Role of health professionals <ul><li>Help clients prioritize their health goals </...
Total Diet Approach Over-reliance on supplements Healthy eating pattern + supplements Good versus bad foods Healthy diet o...
Goals of Nutrition Education <ul><li>To encourage a balanced, individualized diet that includes adequate amounts and varie...
Venues for Nutrition Education <ul><li>Need to embrace new venues to reach today’s consumer: </li></ul><ul><li>Internet </...
 
 
 
Application Tips for the Practicing Health Professional <ul><li>Look at the ‘big picture’ of dietary advice; Strike the ri...
 
 
Application Tips (cont) <ul><li>Take an individualized approach to health </li></ul><ul><li>Consider how to reach a broad ...
Application Tips (cont) <ul><li>Embrace newer research and knowledge once validated </li></ul><ul><li>Be open to shifting ...
Actionable Recommendations <ul><li>Avoid vague recommendations such as “Eat less salt” </li></ul><ul><li>More specific is ...
Case Study  <ul><li>Case study: 70 year old women, 5’5”  and weighs 165 lbs. She has type 2 diabetes. She is on “diet only...
What are the possible unintended consequences of the dietary advice given to this woman? What was missing in the doctor’s ...
Resources <ul><li>These tools can help you get the right balance between nutrition complexity and accuracy: </li></ul><ul>...
Resources (cont.) <ul><li>Nutrition and You: Trends 2008. ADA  www.eatright.org/trends2008   </li></ul><ul><li>2008 Food a...
Summary  <ul><li>Simplistic dietary recommendations can easily lead to unintended health consequences. </li></ul><ul><li>B...
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Simplistic Nutrition Recommendations: Unintended Consequences

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I delivered this presentation to the Diablo Valley Dietetic Association January 20, 2010

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  • Our topic this evening is: Simplistic Nutrition Recommendations: Unintended Consequences . Essentially we will be discussing a concept of simplistic recommendations and the pitfalls associated with it. We will talk about it from both the perspective of working with clients on an individual basis as well as from a public health point of view. I’m not going to be sharing a lot of new information but a new way of looking at information we have known for a long time.
  • Here is how we will proceed: I will begin by describing the concept of what we mean by unintended consequences and share some examples I will share some research about how clients and consumers assimilate nutrition information; We will discuss the role of a food grouping system and nutrient rich foods Finally we will talk about application tips and how you can use this information. I have some resources in the packet that I have handed out that we will review. I will also share some online resources. I am happy to send the slides to anyone that might want them – just provide your business card to me after the presentation and I’ll be sure you get them. I have about 45 minutes worth of slides and I would like to encourage lots of discussion. We will wrap up between 7:30 and 7:45. How does that sound?
  • Let me just start by sharing some familiar simple messages: Sometimes it is easy to see when simple message are off base. &amp;quot;Clean your plate&amp;quot; can lead to overeating . Suntanned skin is not a sign of good health but can lead to premature wrinkles and skin damage . A &amp;quot;No pain, no gain&amp;quot; attitude can lead to a sports injury . &amp;quot;If a little is good, then more is better&amp;quot; can lead to supplement overuse or wastefulness and &amp;quot;Starve a cold, feed a fever&amp;quot; has never made any sense.
  • Other times it can be harder to see the unintended consequence of simplistic messages. These are just a few examples of simple yet incomplete messages and the results: Let’s say, an overweight client wishes to lose weight and adopts a singular-focus approach to &amp;quot;Exercise more&amp;quot;. If he does not change his eating habits he may not see his desired weight loss. Another individual may be interested in skin care and diligently uses sun screen. While this is an excellent idea for skin protection, it could inadvertently lead to a vitamin D insufficiency. Yet another client may want to lower blood pressure, and is told to eat more fruits and vegetables. While this is a helpful message, it is incomplete . The DASH study published in 1997 , found that the combination diet with fruit/vegetable and low-fat dairy had twice the blood pressure lowering effect than the fruit/vegetable only regimen. This could make the difference between the client needing hypertensive medication or managing on diet alone. Diets that limit fat intake or avoid sugar could also mean dropping foods (such as nuts or yogurt) that could help attain a health goal.
  • As nutrition professionals, we need to examine the impact of implementing simplistic advice , either provided by us or adopted by the consumer on their own. We need to assess the possible long-term, often unintended, effects these could have on health. The following are some examples of simplistic advice gone awry. Low fat diets, that don’t also consider calories, can lead to more weight gain, as seen during the low-fat craze of the 1990s . The plethora of new low-fat products introduced to help people lose weight, resulted in more weight gain as consumers misinterpreted &amp;quot;low fat&amp;quot; to mean &amp;quot;low calorie&amp;quot; and over-consumed these products. 1971 – 2000 % cals from fat Men 37% to 33% Women 36% to 33% Absolute fat grams increased Does not prove causation may other things going on in environment but may have contributed.
  • Bone loss is often an unintended outcome of weight loss. You need to be watchful of this esp when older people are losing weight. This result can be avoided, however, with careful dietary planning. A weight-loss diet coupled with adequate calcium intake will prevent bone loss and accompanying fracture risk in older people. Poorly planned vegetarian diets , especially those that avoid or severely limit animal foods, may lead to nutritional deficiencies in vitamin B 12, calcium, iron, zinc and other nutrients found primarily in animal foods. Teenagers are especially at risk for poorly planned vegetarian diets. Code for eating disorders Low-carb diets , under-consume whole grains, fiber and B-vitamins which are important in energy metabolism. -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 . The blanket message to avoid sugar or high fructose corn syrup (HFCS) can have the positive result of reducing consumption of empty calorie foods such as sodas and sweetened juice drinks. However, it can also lead some people to avoid nutrient-dense foods, oatmeal and yogurts, although these foods provide a number of important and often under-consumed nutrients. Balance the benefits of the whole grains or calcium versus the extra calories in the food. You want to look at the whole - My kids breakfast foods. These are a few of the numerous examples of possible unintended consequences of following overly simplified dietary advice. Rather than simplifying the message to something that is incomplete, we need to provide clients comprehensive yet actionable advice that promotes health and well-being. The purpose of this course is to provide resources to enable you to more successfully achieve this ideal.
  • A new study published in Diabetes Care found that parents and kids sometimes put too much emphasis on carb quantity at the expense of diet quality. In interviews with 35 8- to 21-year-olds and their parents, the researchers found that some preferred packaged processed foods to &amp;quot;whole&amp;quot; foods, like fruits, whole grains and legumes, because the carb content was readily available on the product labels. These are just a few simple messages that have possible unintended health consequences. Can anyone think of others?
  • Over-reliance on dietary supplements can also result in unintended health consequences. While it seems an easy solution to pop a pill for a little extra nutrition insurance, some consumers rely too heavily on supplements to meet their nutritional needs, or have the misperception that their diet doesn’t matter as long as they take their supplements. Supplements are a concentrated source of nutrients and because they are often not chewed or even consumed with other food, they pose a greater risk of toxicity than food sources of nutrients. Unintended nutrient deficiencies can result from an imbalanced ratio of nutrients in supplements , leading to 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. Supplement-takers often overlook many nutrients and other factors in foods important to our health. Recent research has shown that phytonutrients, fiber, bioactive peptides and other non-nutritive components in our foods are critical to optimal health and prevention of chronic disease; yet most of these factors have not made their way into supplements. Other important health enhancing components in food may have not yet been identified. Although supplements can play a role in a well-thought-out diet, basing one’s diet on the nutrient-rich foods from the five food groups and choosing whole foods whenever possible is the best way to meet nutrient needs. Discuss here: impact of over supplement use
  • Nutrition legislation intended to improve the health of the public could also have unintended negative consequences. For instance, well-intended legislation aimed to address the obesity epidemic and improve school food service have banned certain foods on school campuses based on the quantity of an &amp;quot;offending component&amp;quot; such as fat or sugar. Such bans convey the message to students, teachers and parents that these foods are &amp;quot;bad&amp;quot; and &amp;quot;unhealthy&amp;quot; regardless of how often or in what quantity they are eaten. Banned foods may include pizza for fat content, flavored milk for high-fructose corn syrup , and other nutrient-dense foods that contain fat or sugar. Ironically, the banned foods often pose a healthier option than alternatives (such as sports beverages and diet soft drinks). In addition, food manufacturers can engineer foods to meet the nutritional criteria of the standards but that do not model overall healthy choices. Through fortification, compliant versions of donuts, cookies and toaster pastries meet the &amp;quot;letter of the law&amp;quot; but not the original intent. Also, these well-intended mandates send the message that if a food does not contain any &amp;quot;offending&amp;quot; components, then it is a healthy food. It could lead to the notion that a diet soda is &amp;quot;healthier&amp;quot; than chocolate milk and trans-fat free crackers are &amp;quot;healthier&amp;quot; than nuts.
  • The following data supports the notion that consumers are interested and capable of more complete nutrition messages. Since 1991, the American Dietetic Association has conducted nationwide surveys to assess people’s attitudes, knowledge, beliefs and behaviors around food and dietary habits, to identify trends and to understand how consumers’ attitudes and behavior have evolved over time. The most recent survey, released in Oct 2008 sheds some light on how consumers feel about food and dietary advice. Among the findings, approximately 67 percent, or 3 in 5 consumers, said diet, nutrition and physical activity are &amp;quot;very important&amp;quot; to them personally. Consumers are information-savvy, with 40 percent of them strongly agreeing that they actively seek information about nutrition and healthy eating.
  • The survey also assessed where people get their nutrition and health information. The most popular sources of food and nutrition information were television and magazines. These mediums tend to lend themselves to the sound-byte simplified message. The internet is the third most popular source of information. This medium allows for more complete messages that can be tailored to consumer’s interest and desire for more information. However, the most popular sources were not considered the most credible. Survey participants ranked dietitians, nutritionists, doctors and nurses as the most credible sources. Television, magazines and the internet were scored much lower on the credibility list. Nutrition professionals have the opportunity to go beyond the sound byte, capitalizing on the credibility already built with the public.
  • Unfortunately, the &amp;quot;good foods, bad foods&amp;quot; myth is still being propagated, with over one-half, or 54%, of respondents saying that based on the information they’ve heard, they strongly believe there are some foods that should never be eaten. This percentage has, in fact, increased since 2002 when 43% agreed with the statement. These beliefs, that there are &amp;quot;good&amp;quot; foods and &amp;quot;bad&amp;quot; foods are fueled directly by simplistic nutrition messages that are increasingly common. Along the same lines, 38% strongly agree that they are always hearing information about what not to eat, rather than what they should eat.
  • Consumers have the mindset that food holds a key role in promoting health. According to research conducted by the International Food Information Council: 60% or more of Americans somewhat or strongly believe that certain foods and beverages can provide multiple health benefits. And, more than 80% say they are currently consuming or would be interested in consuming foods and/or beverages for such benefits. It is important for health professionals, educators and others to understand what issues are most important to consumers. This way, we can create effective nutrition and food safety communications that will actually resonate with consumers and help motivate them to implement behavioral change. The average consumer is extremely interested in health and nutrition information and in improving their health and that of their families. This desire in itself gives food and nutrition communicators a great opportunity to help make positive changes in our nation&apos;s health.
  • The remainder of this presentation will focus on nutrition education solutions that diminish the possibility of unintended consequences. These strategies and resources provide the needed balance between accurate, comprehensive information delivered in simple, actionable terms.
  • The USDA has had a long history with food guidance dating back into the early 20th century. These systems represented health and nutrition concerns of the time when they were introduced.
  • The guiding principles that underlie the development of our current MyPyramid system are the same as they were for the original Food Guide Pyramid. The foundation principles are: well-being and overall health, rather than a focus on a particular disease or condition; up-to-date research so that the guidance recommends appropriate levels of nutrients, and the total diet. which balances essential nutrients while also specifying limits on other food components such as fats, cholesterol, and calories. The system is meant to be useful, realistic yet flexible and practical. Finally, the system is designed to be evolutionary.
  • This graph depicts food consumption compared to recommendations for men and women ages 31 - 50. The bars show the percent change needed in food consumption to meet recommendations. The zero line indicates the amount currently consumed, and the bars indicate the percent increase (above the zero line) or decrease (below the zero line) in consumption that is needed to meet recommendations. To meet recommendations individuals need a substantial increase in consumption for three food groups fruits, vegetables and milk. Consumption data is based on NHANES 2001-2002 data
  • Many popular diets, however, are based on limiting or omitting foods from a food group to reduce calorie intake. The very popular low-carb diets all but omitted the grains and fruit groups. There is a wide range of vegetarian diets, but generally, intake from the meat and beans and milk groups are limited. Recent high-protein diets, on the other hand, increase servings from the meat and beans group, often simultaneously reducing needed intake from other food groups. Often, weight-reduction diets will limit or omit dairy foods, based on the faulty presumption that these foods are fattening, in spite of the range of low-fat dairy foods currently available.
  • The result of these diets may be that key nutrients are missing in one’s diet, eventually leading to deficiencies and significant harm to one’s health in the way of chronic disease, fractures, malfunctioning of certain organs, or a myriad of other issues. For example, limiting or excluding dairy foods from the diet results in lower intakes of calcium, magnesium, potassium, riboflavin, vitamins B6, B12, A and D. Diets that are devoid of dairy-foods are linked to prepubertal bone fractures in children, osteoporosis in adults, and increases risk for hypertension and colon cancer. Calcium binds free bile acids and fatty acids into insoluble complexes, possibly reducing their ability to damage colonic epithelial cells. Calcium may also directly inhibit cancer cells from dividing, thus ensuring normal growth and differentiation of colon cells. Dairy foods exert stronger anti-cancer effects on colon cancer than calcium supplements, however, indicating that dairy products contain other factor(s) that also act in a protective manner. Low-carb diets, as mentioned earlier, could lead to under-consumption of whole grains and fiber, dietary components linked to reduced risk of coronary heart disease, diabetes, constipation and diverticulosis and that may aid in weight management. In addition, the grain group provides B-vitamins for energy metabolism, a healthy nervous system, and prevention of fetal neural tube defects. High protein diets, often based on animal foods, may lead to the increase in fat and saturated fat consumption, with long-term implications to coronary heart disease, diabetes, stroke and several types of cancer. In addition, high protein diets are commonly devoid of high-carbohydrate, high-fiber plant foods that help lower cholesterol again, increasing risk for heart disease.
  • In this era with about two-thirds of our population overweight or obese, it is important to educate the client on how to choose nutrient-rich foods as the basis for their diet. These foods which provide substantial amounts of vitamins, minerals and other nutrients for relatively few calories help to ensure that consumers get adequate nutrients without over-consuming calories. Nutrient-rich foods align with the Dietary Guideline&apos;s definition of a &amp;quot;healthy diet&amp;quot; and MyPyramid&apos;s five food groups. They 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
  • This is a resource you may not be familiar with. The Nutrient-Rich Foods Coalition has done considerable work in advancing scientific and market research to develop tools to help people understand and incorporate nutrient-dense foods into their eating pattern. The coalition is comprised of leading scientific researchers, communications experts and agricultural commodities. Their efforts support the 2005 Dietary Guidelines for Americans and MyPyramid and encourage widespread research and educational efforts that help consumers make more nutrient-rich food choices.
  • This coalition has developed a comprehensive website devoted to helping consumers make the most of their food choices, optimizing nutrient intakes within calorie goals. Some of the resources on this website include: -Recipes and meal ideas based on the nutrient-rich concept -How to navigate the grocery store to make healthy food purchases -A shopping list highlighting nutrient-rich foods from each food group -Tips on how to read nutrition labels -Information on portion control -Easy ways to add nutrients to meals -Tips on making healthful choices while eating out, and -How to fit in &amp;quot;fun&amp;quot; foods in moderation.
  • Front-of-package labeling and nutrient profiling systems are coming into vogue as food manufacturers, supermarket chains, trade associations and health organizations make attempts to direct consumers toward &amp;quot;healthier&amp;quot; choices in a matter of seconds. Currently there are over 25 different nutrient-scoring systems in the U.S. alone, all of which are based on different criteria to classify foods as more or less healthy.
  • Not surprisingly, these systems come with their pros and cons. Front of Package labels offer consumers, quick and easy-to-use guidance. The average consumer spends about 7 seconds choosing a food product. Given this reality it is unreasonable to expect a complicated guidance system would be effective. In addition, profiling systems allow consumers to more easily compare products side-by-side, without having to weed through the more complicated information on the Nutrition Facts panel.
  • There are however many disadvantages and unintended negative consequences of these systems. Because they rate individual foods rather than whole diets, they encourage consumers to perceive foods as either &amp;quot;good&amp;quot; or &amp;quot;bad&amp;quot;, a philosophy many nutrition professionals have discouraged for years. These labels also have no way to account for individual needs and dietary goals; they rate foods the same regardless of a consumer’s age, ethnicity, lifestyle and disease risk. Finally, because the criteria upon which the profiling systems are based are limited to a few nutrients, it is easy to overlook other nutrients that can play an important role in health. For example, nuts, cheese and meats might be classified to a &amp;quot;less healthy&amp;quot; category because of their fat content, when in fact they have numerous very positive nutrients to offer. It is easy to see how over-emphasis on nutrient profiling systems could lead consumers to make food choices that, in the long term, could lead to unintended consequences such as complete avoidance of certain foods and inability to individualize diets. These systems can be useful tools yet are not intended to be the &amp;quot;end-all&amp;quot; in nutrition advice.
  • When evaluating nutrient profiling systems and front of package labels, consider the following: - Is the scoring or program nutrient criteria publicly available and/or published in scientific journals ? - Is there objective and balanced scoring between positive and negative nutrients ? - Does it reflect the scientific principles of the 2005 Dietary Guidelines for Americans and MyPyramid? -Is it flexible enough to accommodate changes anticipated with the 2010 revision of the Dietary Guidelines?
  • In addition: Are there 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 of the supermarket? These factors should be considered before recommending a particular profiling system to consumers and clients.
  • Nutrition education is most effective when it is individualized, since there are a broad array of factors playing a role in health. Research on the importance of nutritional individualization continues to accumulate at a rapid pace. From non-modifiable factors such as age, gender, genetics, and ethnicity; to modifiable ones such as activity level, smoking, social and lifestyle choices, we have more knowledge now than ever before about nutrients, foods and eating patterns that will help optimize health and prevent chronic disease.
  • Our role as health professionals is to help clients prioritize their health goals and identify specific and realistic means to accomplish those goals, taking individual factors including disease risk, dietary preferences, health goals and lifestyle into account to make their plan realistic and actionable. Using the food grouping system as a base creates an eating pattern that can be sustained over the long term. Its flexibility accommodates a wide range of preferences, goals and health outcomes, and it will ensure adequate intake of individual nutrients which can easily be overlooked amidst other health concerns.
  • I think there is a lot to be said for emphasizing guidelines that focus on total intakes rather than on the nutritional merits or disadvantages to single foods alone. Whether individuals choose MyPyramid as the guide or DASH or some other example, the total diet approach really beats the single-minded focus on a specific food or foods alone. And also recommendations that focus on total intake have room for dietary supplements, when they are necessary, like for folic acid among pregnant women or women at risk of pregnancy and vitamin B 12 for very old people, while not overemphasizing them. Dietary supplements are just that, they are supplements. They are not replacements for the diet. They are best used on top of and not instead of a healthy eating pattern.
  • The goals of nutrition education are to: - Encourage a balanced, individualized diet that includes adequate amounts and variety of foods from all food groups - Dispel the &amp;quot;good&amp;quot; and &amp;quot;bad&amp;quot; foods perspective - Discourage extreme dietary restrictions Success is more often seen when we encourage small steps that lead to long-term compliance.
  • It is clear that nutrition education is important for consumers to be successful with eating balanced diets that promote optimal health. Unfortunately, time and opportunity for nutrition education is limited. The traditional mode of educating the consumer through their health care provider may no longer be realistic due to the infrequency the average person meets with their provider and increased demands on their provider’s time. Fortunately we can now reach consumers with health and nutrition messages through electronic media such as websites, listservs, blogs, podcasts and electronic newsletters. In addition, worksite wellness centers are on the rise and are an effective means to disseminate nutrition information. We need to be open to embrace these new venues, offering clients and consumers information in a way that is convenient for them. More importantly, while using these new venues, we need to learn strategies that avoid simplistic messages and instead use techniques that lead to appropriate and lasting behavior change.
  • The next few slides summarize best practice application tips for the practicing health professional, that encourage healthy eating while avoiding overly-simplistic dietary advice. Encourage clients to look at the &apos;big picture’ regarding diet and food choice decisions. Some cueing questions you might use to meet this objective: &amp;quot;If you make a change in this one area, how will it impact other aspects of your health?&amp;quot; &amp;quot;Are there other dietary adjustments that you should make?&amp;quot; Discourage clients from omitting a whole food group from their diets. Such omissions can result in nutrition deficiencies. Consuming a variety of foods from all food group ensures adequate and sufficient intake of all nutrients. Although supplements are appropriate in certain cases when it is not feasible to obtain adequate amounts of specific nutrients from food, encourage clients to get the base of their nutrients from foods rather than supplements.
  • Remind clients that they are individuals and what is right for one person may not be the best advice for them. Remind them of their individual health goals, focusing on their specific needs and personal preferences that include ethnic and cultural preferences. Help them determine ways to manage their individual needs while meeting the needs of others in their family. Consider alternative methods of reaching consumers with balanced dietary messages if individual consultation is not financially possible. Providing articles in healthcare newsletters, developing or posting materials online or on listservs and holding group sessions are a few strategies to reach the increasingly time-stressed consumer. Give clients more credit; don’t under-sell them with nutrition information. We need to resist the temptation to over-simplify nutrition information for fear that clients can only understand very simple (yet incomplete) messages. As we saw in the consumer research, the average consumer is very motivated toward improving their health, and can handle the information that it will take to get them there.
  • We also need to encourage colleagues and allied health professionals to be willing to embrace newer research and knowledge when it is validated. This may mean shifting paradigms, to ensure we don&apos;t fall into the pattern of giving &amp;quot;one size fits all&amp;quot; nutrition advice. We also need to stay abreast of recent research and avoid being swept up by the &amp;quot;nutrition issue of the month&amp;quot; propagated by the media and special interest groups who lack the scientific background to evaluate nutrition issues in an unbiased fashion.
  • Dr Peggy Papathakis is an assistant professor in the Department of Food Science and Nutrition at California Polytechnic State University in San Luis Obispo California. She has 25 years of experience as a clinical dietitian specializing in the field of pediatrics. When counseling clients about nutrition, it is important to help them prioritize their health and nutrition goals and to include suggestions that the client can understand and achieve taking into account their individual situation. Guidelines such as “Eat more fruits and vegetables or don’t add salt to foods” are too vague of a suggestion to act upon. To provide the best counseling, it is helpful to determine individual factors such as what the person enjoys to eat, their food preparation skills, their barriers towards dietary changes and what they can afford. This requires listening to the client and collaborating to determine what will work best in their situation. Developing a specific plan such as, “drinking milk instead of soda or juice for dinner” or “include a fruit and vegetable at lunch and dinner” is something that the client can remember and envision doing. Importantly, this recommendation is specific and measurable, and at the follow-up visit, you can determine if it was successfully met.   Many times I have had clients referred from the physician because they are not following their No Added Salt diet. The clients tell me that they are following their diet exactly as they were instructed because they are not adding salt to foods anymore, just like their doctor told them. Upon review of the clients sodium intake, I see that they are still consuming 5-6 gm sodium/day, significantly above the 3-4 gm goal. We know that for most people, added salt provides only 15% of total sodium intake, while the majority of dietary sodium comes from processed or convenience foods, and from meals purchased away from home. While it is wonderful that the client has successfully made this change, there is the unintended consequence of the simplistic diet advise - that it did not significantly reduce sodium intake because it did not take into account the larger contribution to sodium intake from other foods.   When deciding the best course of action, it is important to consider the needs of the whole person, rather than just their disease state. You want to think about healthy eating in the broadest sense. For example, a mother of an obese child asked me how many diet sodas her daughter could drink per day. As is the case with many nutrition questions, there is no clear cut answer. I turned the question back to her and asked, “If your daughter was not overweight, how many sodas would you let her drink?” She paused for a moment, and was glad to be reminded of her larger role as a mom to provide her child with good eating habits overall, in addition to managing her weight gain.   In order to help clients be successful in making changes, food and nutrition goals must be actionable and achievable. As health care providers, we must individualize the goals, and make them specific and measurable.
  • Let&apos;s take a moment to consider the following case study: A 70 year old women is 5’5&amp;quot; and weights 165 lbs. She has type 2 diabetes. She is on diet only therapy for her diabetes 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. Answer the following multiple choice questions regarding this case. Once you&apos;ve read all the options, click on the round radio button with your answer, then click &apos;submit&apos; to see the correct answer.&amp;quot;
  • What is the unintended consequence of the dietary advice given to this woman? Weight loss Blood sugar control No real diet improvement and possible worse dietary balance None of the above What was missing in the doctor’s initial treatment plan? Suggestions to increase physical activity Adding strength training Suggesting a diabetes support group All of the above Cutting out the juice consumption since she can only handle one change at a time. Whole fruits that she enjoys eating that she could substitute for the juice; as well as ways to eat favorite vegetable and low-fat dairy foods more often. Cutting back calories to 1200 per day since people with diabetes need to lose weight. Avoiding desserts and joining a gym.
  • High quality nutrition education tools can help you achieve the goal to provide comprehensive nutrition education. These tools can help you strike the right balance between nutrition complexity and accuracy. MyPyramid has some excellent tools including an online menu planner and food tracking worksheets. The USDA Food and Nutrition Service has a wide range of tools on their Eat Smartl Play Hardl Healthy Lifestyle website. Finally, Meals Matter, a meal planning website sponsored by the Dairy Council of California, has a Personal Nutrition Planner that can help consumers develop realistic plans to improve their food choices.
  • If you would like to review in greater detail information that is referenced in this course, you may go to the American Dietetic Association’s eatright.org website for the complete report, Nutrition and You: Trends 2008. You also may wish to visit the International Food Information Council website to review the 2008 Food and Health Survey also referenced during this course.
  • In summary, simplistic dietary recommendations can easily lead to unintended health consequences. When considering dietary changes, be sure to take into account the long-term health consequences and the overall impact the change could have. A food grouping system such as MyPyramid should be the basis for a balance diet - including all food groups. And finally, choosing nutrient-rich foods from all food groups is the best way to optimize nutrition and keep calorie intake appropriate. This concludes the PowerPoint slide portion of this course. For handouts and additional reading material and/or to take the test to submit for CE credits, return to the course introduction page on the Dairy Council of California website.
  • Simplistic Nutrition Recommendations: Unintended Consequences

    1. 1. Simplistic Nutrition Recommendations: Unintended Consequences Maureen Bligh, MA, RD January 20, 2010
    2. 2. Outline <ul><li>Background </li></ul><ul><li>Recent research on consumer attitude & behaviors </li></ul><ul><li>Role of food grouping system </li></ul><ul><li>Role of nutrient-rich foods </li></ul><ul><li>Nutrition education application tips </li></ul><ul><li>Summary and action steps </li></ul>
    3. 3. Background: Common Simple Messages <ul><li>Clean your plate </li></ul>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
    4. 4. 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.
    5. 5. Examples of simplistic recommendations and outcomes <ul><li>Dietary Guidelines “Choose Low-fat foods” </li></ul><ul><ul><li>Gave unintended permission to consume more low- fat foods which are not always lower in calories </li></ul></ul><ul><ul><li>1971 - 2000 </li></ul></ul><ul><ul><li>% kcal/fat reduced </li></ul></ul><ul><ul><li>Total kcal increased </li></ul></ul><ul><ul><li>Total gm fat increased </li></ul></ul>
    6. 6. Examples of simplistic recommendations and outcomes (cont.) <ul><li>Weight loss diet  Bone loss </li></ul><ul><li>Vegetarian  Nutrient deficiencies </li></ul><ul><li>Low-carb  Nutrient deficiencies and chronic disease </li></ul><ul><li>Sugar  Avoid some nutrient-rich foods </li></ul><ul><li>Am J Clin Nutr 2007 Apr;85(4):972-80 </li></ul><ul><li>www.dairycouncilofca.org/PDFs/Unintended-consequences.pdf </li></ul>
    7. 7. More examples <ul><li>Diabetic kids may focus too much on carb counting </li></ul><ul><ul><li>December Diabetes Care </li></ul></ul><ul><li>Consumers Stress over Organic Eating </li></ul><ul><ul><li>Blog post on eatright.org </li></ul></ul><ul><li>Other examples? </li></ul>
    8. 8. Foods versus Supplements <ul><li>Unintended consequences can also result from overuse of supplements: </li></ul><ul><li>Overdosing on single nutrients </li></ul><ul><li>Nutrient deficiencies secondary to imbalanced ratio of supplemental nutrients </li></ul><ul><li>Overlooking non-nutritive components in foods </li></ul><ul><li>JADA 2005:105(8):1300-1311 </li></ul>
    9. 9. Possible outcomes of nutrition legislation and regulations <ul><li>Legislated solutions for school food service and school vending </li></ul><ul><li>Banning or limiting certain foods  perception that those foods should always be avoided e.g. pizza, flavored milk </li></ul><ul><li>Allowed foods  </li></ul><ul><ul><li>diet soda, engineered donuts and toaster pastries; are these “healthy”? </li></ul></ul>
    10. 10. Nutrition and You: Trends 2008 <ul><li>67% of consumers said diet, nutrition and physical activity are “very important” to them personally. </li></ul><ul><li>40% of people strongly agreed with the statement: I actively seek information about nutrition and healthy eating </li></ul><ul><li>www.eatright.org/trends2008 </li></ul>
    11. 11. Nutrition and You: Trends 2008 <ul><li>The most popular sources of food and nutrition information were TV (63%) and magazines (45%), followed by the internet. </li></ul><ul><li>Dietitians, nutritionists, doctors and nurses were ranked as the most credible </li></ul><ul><li>www.eatright.org/trends2008 </li></ul>
    12. 12. Nutrition and You: Trends 2008 <ul><li>54% of people think there are foods that they should never eat. </li></ul><ul><li>38% strongly agree that they are always hearing information about what NOT to eat, rather than what they SHOULD eat. </li></ul><ul><li>www.eatright.org/trends2008 </li></ul>
    13. 13. International Food & Information Council Consumer Survey <ul><li>>60% believe that certain foods and beverages can provide multiple health benefits </li></ul><ul><li>>80% say they are consuming, or would be interested in consuming, foods and/or beverages for such benefits. </li></ul><ul><li>http://www.ific.org/research/foodandhealthsurvey.cfm </li></ul>
    14. 14. Food Guidance Systems: Old-school tools can still solve new-age problems
    15. 15. History of USDA’s Food Guidance 1940s 1950s-1960s 1970s 1992 2005 Food for Young Children 1916
    16. 16. Guiding Principles— Unchanged Overall Health Up-to-Date Research Total Diet Useful Realistic Flexible Practical Evolutionary
    17. 17. MyPyramid Recommendations Compared to Consumption Increases Current Intake Decreases Fruits Vegetables Grains Meat & Beans Milk Bars show percent change needed in consumption to meet recommendations
    18. 18. Diets skewing food-grouping approach <ul><li>Simplified diets are often based on limiting or omitting foods from a certain food group to reduce calorie intakes </li></ul><ul><li>Low-carb diets limit breads, grains & cereals and fruit group </li></ul><ul><li>Vegetarian diets reduce intake from meat, beans and nut group, and sometimes dairy group </li></ul><ul><li>High protein diets increase intake from meat, beans and nut group, to the possible detriment of intake from other groups </li></ul><ul><li>Many diets limit or omit dairy based on the false presumption that dairy foods are fattening. </li></ul>
    19. 19. Unintended consequences of limiting food groups Heart disease Diabetes Stroke Cancer Low in carbohydrates, fiber High in saturated fat High protein Heart disease Constipation Diverticulosis Neural tube defects Low in whole grains, fiber, B-vitamins, folate Low carb Fractures Osteoporosis Higher risk of hyper-tension & colon cancer Low in calcium, magnesium, potassium, riboflavin, Vit B6, B12, A, D Low dairy Possible long-term health consequences Nutrient implications Diet
    20. 20. Choose nutrient-rich foods from all food groups <ul><li>The nutrient-rich food categories are aligned with the Dietary Guideline's definition of a &quot;healthy diet&quot; and MyPyramid's five food groups, and include: </li></ul><ul><li>Brightly colored fruits and 100% fruit juices </li></ul><ul><li>Vibrantly colored vegetables and potatoes </li></ul><ul><li>Whole, fortified and fiber-rich grain foods </li></ul><ul><li>Low-fat and fat-free milk, cheese and yogurt </li></ul><ul><li>Lean meat, poultry, fish, eggs, beans and nuts </li></ul>
    21. 21. Nutrient-Rich Foods Coalition <ul><li>Partnership that brings together leading scientific researchers, communications experts and agricultural commodities </li></ul><ul><li>Dedicated to advancing scientific and market research to develop tools to help people understand and incorporate nutrient-dense foods into their healthy lifestyle. </li></ul><ul><li>Supports the 2005 Dietary Guidelines for Americans and MyPyramid </li></ul><ul><li>www.nutrientrichfoods.org </li></ul>
    22. 22. NRFC website <ul><li>Recipes and meal ideas </li></ul><ul><li>Navigating the grocery store </li></ul><ul><li>Nutrient-rich shopping list </li></ul><ul><li>Guide to nutrition labels </li></ul><ul><li>Portion control basics </li></ul><ul><li>Adding nutrients to meals </li></ul><ul><li>Eating out </li></ul><ul><li>Fitting in “fun” foods </li></ul><ul><li>www.nutrientrichfoods.org </li></ul>
    23. 23. New considerations: Front of Package (FOP) Labeling
    24. 24. Front of Package (FOP) Labeling <ul><li>Pros </li></ul><ul><ul><li>Consumers want a simple, easy to use system and quick guidance. </li></ul></ul><ul><ul><li>Ease of comparing similar food products (e.g. cereals, snack foods) </li></ul></ul>
    25. 25. Front of Package (FOP) Labeling <ul><li>Cons </li></ul><ul><ul><li>Systems encourage good food – bad food perceptions among consumers </li></ul></ul><ul><ul><li>Does not allow for individualization </li></ul></ul><ul><ul><li>Some nutrient-rich foods may receive low ratings e.g. nuts, cheese, meats. </li></ul></ul>
    26. 26. What to look for in a FOP label? <ul><li>Is the scoring or program-nutrient criteria: </li></ul><ul><li>Publicly available or published in scientific journals? </li></ul><ul><li>Objective and balanced between positive and negative nutrients? </li></ul><ul><li>Scientifically representative of consensus dietary guidance—2005 Dietary Guidelines for Americans and MyPyramid </li></ul><ul><li>Is it flexible to accommodate changes anticipated with the 2010 revision of the Dietary Guidelines? </li></ul>
    27. 27. What to look for in a FOP label? <ul><li>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? </li></ul><ul><li>Can the program information be transferred to other settings when food choices are made outside the supermarket? </li></ul>
    28. 28. Optimal Diet Genetics & Ethnicity Preferences, Aversions, Intolerances Social, Cultural, Religious Factors Lifestyle & Environmental Factors Smoking Age & Gender Disease risk Activity level Individualizing nutrition advice
    29. 29. Individualization in nutrition advice: Role of health professionals <ul><li>Help clients prioritize their health goals </li></ul><ul><li>Identify specific and realistic measures to accomplish those goals </li></ul><ul><li>Use the food guide system as the basis for forming a sustainable, healthy eating plan </li></ul><ul><ul><li>Flexible enough to accommodate a wide range of goals and health concerns </li></ul></ul><ul><ul><li>Ensures adequate intake of individual nutrients </li></ul></ul>
    30. 30. Total Diet Approach Over-reliance on supplements Healthy eating pattern + supplements Good versus bad foods Healthy diet over time Single-foods approach Dietary patterns, e.g. MyPyramid or DASH Diet Emphasis on nutrients Total intake of foods Instead of…. Focus on……
    31. 31. Goals of Nutrition Education <ul><li>To encourage a balanced, individualized diet that includes adequate amounts and variety of foods from all food groups </li></ul><ul><li>To dispel the “good” and “bad” foods perspective </li></ul><ul><li>To discourage extreme dietary restrictions </li></ul><ul><li>Small steps that lead to long-term compliance </li></ul>
    32. 32. Venues for Nutrition Education <ul><li>Need to embrace new venues to reach today’s consumer: </li></ul><ul><li>Internet </li></ul><ul><li>Websites </li></ul><ul><li>Listservs </li></ul><ul><li>Electronic newsletters </li></ul><ul><li>Wellness centers </li></ul>
    33. 36. Application Tips for the Practicing Health Professional <ul><li>Look at the ‘big picture’ of dietary advice; Strike the right balance between info overload and simplicity </li></ul><ul><li>Include recommendations for all food groups – with action steps for priority issues </li></ul><ul><li>Encourage foods first </li></ul>
    34. 39. Application Tips (cont) <ul><li>Take an individualized approach to health </li></ul><ul><li>Consider how to reach a broad range of consumers with balanced dietary messages </li></ul><ul><li>Give them more credit; don’t “under-sell” clients with nutrition information </li></ul>
    35. 40. Application Tips (cont) <ul><li>Embrace newer research and knowledge once validated </li></ul><ul><li>Be open to shifting paradigms & pass that along to clients. </li></ul>
    36. 41. Actionable Recommendations <ul><li>Avoid vague recommendations such as “Eat less salt” </li></ul><ul><li>More specific is better – determine cooking skills, food preferences to develop specific action plan </li></ul><ul><li>Develop plan that will make most difference </li></ul>
    37. 42. Case Study <ul><li>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. </li></ul>
    38. 43. 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 .
    39. 44. Resources <ul><li>These tools can help you get the right balance between nutrition complexity and accuracy: </li></ul><ul><li>MyPyramid Menu Planner </li></ul><ul><li>MyPyramid Food Tracking Worksheets </li></ul><ul><li>Eat Smart. Play Hard. Healthy Lifestyle </li></ul><ul><li>Personal Nutrition Planner </li></ul>
    40. 45. Resources (cont.) <ul><li>Nutrition and You: Trends 2008. ADA www.eatright.org/trends2008 </li></ul><ul><li>2008 Food and Health Survey: Consumer Attitudes toward Food, Nutrition & Health (IFIC). http:// www.ific.org/research/foodandhealthsurvey.cfm </li></ul>
    41. 46. Summary <ul><li>Simplistic dietary recommendations can easily lead to unintended health consequences. </li></ul><ul><li>Before adopting dietary change, examine the overall impact it will have, particularly on long-term health and wellness. </li></ul><ul><li>A food grouping system such as MyPyramid should form the basis for a balanced diet that can be sustained over the long term. </li></ul><ul><li>Choosing nutrient-dense foods from all food groups is the best way to optimize nutrient intakes while keeping calorie intake in check. </li></ul>

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