What about those Fruits and Vegetables? It depends....

I have seen more than one study challenging the utility - and even sensibility - of recommending an increase in the consumption of fruits and vegetables as a means to maintain or lose weight.  In the US, the recommendation is either just a general eat more or a more specific eat at least 5 servings.  In other countries, for example Australia, the recommendation is 2 fruits and 5 vegetables.  Walter Willett and the folks at HSPH recommend more vegetables than fruit.  

To be clear, non-starchy vegetables, specifically, and some fruits have been shown to improve health, possibly through their antioxidant properties.  But recently, using Eat More Fruits and Vegetables as an obesity prevention/treatment strategy, has come into question.  I have been concerned about the recommendation for some time, and that is why I promote Willett’s new food pyramid over the USDAs food guidance.

My concerns about fruit and vegetable promotion and all food related promotion is that people don’t hear, because its seldom said, eat more of this (x) INSTEAD of that (x).  People do not get the message that adding health promoting foods such as fruits, vegetables, whole grains, healthy oils, fish, etc. needs to be qualified.  The healthy foods are particular and only stay healthy if they remain nutrient dense (e.g., potatoes are a starchy vegetable which we do NOT need to increase, and kale is GREAT, kale cooked in fat back/butter is NOT GREAT).

Of course, fruits and vegetable calories are of a higher nutritional value than ones from chips, hotdogs and soda, but 1) the choice of fruit (e.g., a plum vs kiwi) or vegetable, 2) the preparation of that fruit or vegetable, 3) the size of that fruit or vegetable (i.e., jumbo fruits (bananas, oranges, apples = 2 or 3 servings), and 4) the overall amount of calories consumed will determine if adding fruits and vegetables to ones diet aids in weight loss.  The bulky, nutritious, fiber rich peppers, summer squash, onions and mushrooms should bulk up one's plate and reduce the caloric density of a meal– these foods should replace (or reduce) meat and pasta for instance.

Two studies released this month,(Charlton et al., 2014; Kaiser et al., 2014), found that increasing fruit and vegetable intake did not lead to weight loss and in some instances, led to weight gain.  The Kaiser et al study used robust criteria to evaluate randomized control trials (RCT) and though the RCTs themselves had limitations, the review of them was sound.  In the authors’ words, the upshot is this…. 

Purchasing and preparation barriers need to be addressed.  Interventions should provide more instruction on how to prepare vegetables in such a way as to not increase their energy content (such as not preparing vegetables with fat (eg not frying or serving with butter)… and….Although many fruits and vegetables [F/V] have demonstrable positive health benefits, recommending increased F/V consumption to treat or prevent obesity without explicitly combining with methods to reduce intake of other energy sources is unwarranted (Kaiser, et al).

One of the main reasons I started my You Tube channel was to show people how to cook foods without turning them into calorically dense meals or snacks.  So, do eat more fruits and vegetables as you eat LESS meats, breads, and desserts.

Charlton, K., Kowal, P., Soriano, M. M., Williams, S., Banks, E., Vo, K., & Byles, J. (2014). Fruit and Vegetable Intake and Body Mass Index in a Large Sample of Middle-Aged Australian Men and Women. Nutrients, 6(6), 2305-2319.

Kaiser, K. A., Brown, A. W., Brown, M. M. B., Shikany, J. M., Mattes, R. D., & Allison, D. B. (2014). Increased fruit and vegetable intake has no discernible effect on weight loss: a systematic review and meta-analysis. The American journal of clinical nutrition, 100(2), 567-576.

Differentiating between the healthy thin and the sick thin

    Just a quick post regarding the uproar over the study that indicated lower weight persons did not live as long as mildly overweight ones and the somewhat associated Mortality Index.
   Unfortunately, the current issue of the Nutrition Action Healthletter is not yet available on line.  It does a great job breaking down the recent study published in JAMA.  The research findings got a lot of people excited and a few scientists upset.  Recall that Walter Willett referred to them as "rubbish."  Read more at Harvard School of Public Health HERE.
   The problem, many scientists agree, is two fold.  One is including smokers or former smokers into the study and the other is not excluding people with chronic diseases that cause weight loss.  I appreciate the desire to leave out former smokers, but I think instead of ruling out all former smokers, another criteria could be set.  For example, a person who smoked 15 years or less and has been completely tobacco free for 15 years before the study.  That could be further nuanced by adding a pack per day limit. What is clear, smoking is a big problem.  It makes people sick and smokers have lower weights than nonsmokers, in general.  (I read that all the time, but I sure know a lot of obese smokers).
    The second issue is the Mortality Index constructed by researchers at UCSF.  This assessment is meant to be used by physicians and only with patients over the age of 60.  Of course, you know that if we have access to it, we are going to "test" ourselves.  I did.  The issue again is the weight question.  Here if your BMI is under 25 you get a point and "low score wins!"  To handle this possible error, my thought is this:   A physician giving this test to a patient he or she knew, could decide whether or not the patient's normal or low normal weight was healthy or concerning. If the patient was not ill (points for smoking are in another question) and had a normal or low normal weight for most of their adult life, they should not get penalized.  The problem with low weight is its association with wasting diseases or smoking and nothing more.
   Remember you are not supposed to take this test yourself, but don't you want to know what the fuss is about?  Click here.  

Is Being Overweight Healthy?

In a word....NO.

A researcher is making news for her findings – and some of it might not be the kind of news she would like to make.  Dr. K.  Flegal has completed a study that she says shows being somewhat overweight is better than being low weight.    Her study supports the present belief that obesity is related to heart disease, diabetes, some cancers and all-cause mortality, but challenges the belief that overweight does the same thing.  The problem with her study, some say, is that she is including people who are thin not because they are fit, but because they are unhealthy – having terminal illnesses and or being smokers.

Her work stands in stark contrast to most studies and in and of itself does not merit a reversal of public health recommendations.  It certainly is not an excuse for YOU to accept a weight that is high for yourself. 

Here I will requote Dr. Walter Willett – an epidemiologist with Harvard School of Public Health who was interviewed by Allison Aubrey.  Please see her article here.  These quotes come directly from her story:

"This study is really a pile of rubbish and no one should waste their time reading it," he says.

Also, he says the analysis doesn't address the bigger, more important issues of quality of life. If an overweight person does live longer — is he or she living with chronic diseases?

"We have a huge amount of other literature showing that people who gain weight or are overweight, have increased risk of diabetes, heart disease, stroke, many cancers and many other conditions," Willett says.

When Walter Speaks

In the last issue of the New England Journal of Medicine (a research/scientific publication), Walter Willett and his colleague David Ludwig (both MDs and and PhD/DrPhs) submitted a perspective on the DGA 2010.

 I just reread the article in order to offer some highlights in the blog, but as I was doing so, I thought that it would be beneficial for you to read every word of it.  It is not very long and it is available for free by clicking this NEJM link.

The points that I elect to bring to your attention follow.  The authors feel that the guidelines have strengths and weaknesses. They bemoan the fact that there was not a lot press around them, especially because we are in a "nutritional crisis." They support the recommendations on foods to include (you should know what they are from all my blogging about them) and on the foods to limit.  They point out that there is not enough emphasis on what Americans need to limit and that nutrients should not be the focus.  The focus should be the foods themselves.  This is an important distinction which fits perfectly with my argument that nutrient supplements do not do for our bodies what nutrients in food do.  Dr. Willett is saying that the things we need to avoid or limit, such as saturated fats, occur in FOODS.  He states that a better message would be that "Americans must reduce consumption of red meat, cheese, butter, and sugar,"  and adds that if this message had been disseminated it "... would have offended powerful industries."  The Myplate graphic is also frowned upon, as you know, Harvard has made a better Myplate which you can read about in this past blog post.

The same concern about total fats versus saturated fats is iterated in this article (I say same, because I have blogged about that TOO!) as is concern over refined grains and sugars - and sodas.  The discussion regarding how the limit on total fat is having an adverse effect on programs such as school lunches is also seen in the IOMs recommendations on Front of Pack labeling (not mentioned in this article, but you may recall that the FOP system is going to list Sat Fat not Total Fat because Total Fat numbers could potentially drive people away from healthy fats).

I urge you to take a look at the published article.


*****not only was I the first person in the pool today - I dove in - yup.  Still cold though....*****

Retro Post!

This is a copy of a news story I wrote in March of 2007 when I was still an employee of Wake Forest University Baptist Medical Center. I tried NOT to edit it too much :) You can see that some of the issues have remained in the press and that maybe, my writing skills have improved since this was written!


News Notes

Special Edition

The information in today’s newsletter is derived directly from a conference I attended earlier this week. This was part of the research series brought to us by the Women’s Health Center of Excellence. I did attend sessions on weight loss surgery, diabetes, fad diets and most importantly life style factors and disease. In fact, the reason I took the day off from work was to hear the man, the physician and doctor of public health whom I esteem above all others, speak on the prevention of the chronic diseases that are affected by life style and diet. He is Walter Willett, Harvard professor and researcher. This is my best representation of what I heard during his lecture. He also has a new book for the public titled Eat, Drink and Weigh Less. I highly recommend any and all of his publications.

There were pearls here and there in his lecture. But I will begin with the bottom line. Based on careful analysis of two large, rigorous and scientifically valid prospective cohort studies,[ one the Nurses Health Study, the other the Physician’s Health Study] ….it is believed that the following life style choices are protective against heart disease and diabetes… Moreover, as much as 80 to 90 % of the cases of these diseases could have been prevented…. [ NOTE: Dr. Willett did not provide a presentation out line and I am fallible. There could be error here, by misunderstanding or even a typo… check the facts ok!]

Okay, the LIST of things to DO!!!!!

To prevent heart disease
1) be a nonsmoker
2) keep the BMI (body mass index) below 25 and lower is better (to 20) but he is choosing a number that more persons might be able to attain. [realism…]
3) exercise more than ½ hour a day every day. He suggested brisk walking though he said running is better. Again he said he is being realistic for the majority.
4) choose what you eat! Low to no trans fats, high ratio of polyunsaturated/saturated fats, low glycemic load foods, high CEREAL fibers, high fish intake (3x/week), consume the recommended daily allowance of folate
5) alcohol (any kind not just wine, it’s the ethanol stupid – little joke there, but yes, it is the ethanol that appears protective as long as the folate intake is not lacking. Very important that you hear that part, FOLATE + ½ glass per day of alcohol o prevent heart disease

For diabetes Dr. Willett said it was the same but not the fish and folate recommendations.

He said that prevention for colon cancer also adds that one should not have more than two servings of red meat a week (serving is 3 oz which is NEVER the size a restaurant provides!). Alcohol and Folate rule does apply and I think the alcohol recommendation was slightly higher. Screening for this cancer is strongly recommended in the literature.

Dr. Willett does not recommend dairy products or calcium overmuch. He noted some bad outcomes with too much calcium, regardless of fat content in the dairy products. He notes that we are the only country that consumes so much dairy. Some use none. He noted research that does NOT show that calcium protects against fracture. A new to me "factoid". Height is a risk factor for fractures… long bones.. Also the hormones in milk accelerate growth in our kids leading not only to early puberty, but breast cancer and fracture risks because of the growth…

He promotes Vitamin D… I hinted at that a few weeks ago and now I am going to make changes because of it……. All he recommended in regards to supplements is Vit D 1000 IU a day and the RDA for Folate…. He suggested a multivitamin with 1000 D, but I haven’t seen one (yet) [actually I went shopping between the above and the below, I did not see any multivitamins with more than 400 IU of D but the D tablets came themselves in 400 and a 1000. Be careful you don’t over do it if you are taking multiples, i.e. your calcium might have D and your Multivitamin, so don’t add 1000 of D if they both already have some]

Dr. Willett reviewed research that helped us track down why some countries had more rates of certain disease than others. He spoke about the mistakes made with fat free diets and the error of the original food guide pyramid. He addressed the butter v margarine and Trans Fat issue.

He believes that the biggest issue and the one that has had the most impact on this increase in obesity, heart disease, diabetes and some cancers is the failure to differentiate between the types of fats and the types of carbohydrates in our diets. He supports the positive aspect of fats in olive, canola, and soy bean oils. He encourages consumption of food with poly unsaturated fatty acids or PUFA and of foods with Omega 3 and 6. These fats are correlated in the rigorous research with decrease in heart disease where as trans fats those in processed, and until recently, fried foods as well as saturated fats in red meats, etc are related to increase in heart disease.

Though both are health promoting Omega 3 is better than 6 in this regard: A real pearl for me: Omega 3 fatty acids, often found in fish are the only ones that in research have been shown to control or prevent heart arrhythmia, ( irregular heart beat ) and though they do not stop heart attacks from occurring, they decrease DEATH from the heart attack.. My father’s death certificate states arrhythmia and acute MI… so hmmmm. Food for thought isn’t it.

Oh yes, on that same note. He said that dietary changes such as he proposes are good at ANY age and with any heart disease history. He states that the Mediterranean type diet, low in sat fat, higher in fish and veggies and monounsaturated oils will increase life expectancy. His best quote I thought, “the hydrogenation of oils that leads to the TFAs is done to increase the shelf life of products, but it decreases OUR shelf lives!”

Do you all remember a couple years back I brought up a type of inflammation in the blood that might indicate heart attack risk. The CRP or c reactive protein? WELL he mentioned it and said that trans fat could double it! Oh dear, I notice I am on page three. Better wrap this up. Gosh it’s hard to not repeat everything he said. I suppose the most important thing would be the pyramid that I mentioned earlier. It was a lovely slide.

Shoot. I didn’t get to the carbohydrate issue. Basically it’s the same as I’ve already written. He said that white potatoes should not be in the vegetable category.. He said that white flours, rice, pasta, bread etc are high glycemic foods and he did give credence to the issue that these foods should be avoided or limited. This is especially so if one has an increased BMI. In other words, lean all day active people, like the Chinese of a generation ago, they can eat white rice and not get diabetes!

In July of 2009 I did include Dr. Willett's food pyramid in a post. You can see it here.