Health Promotion

1. Motivating the imperfect, irrational human being

   Published on Monday, October 3rd, 2011

   At the Dietitians NZ Conference in Nelson this year I attended a memorable workshop by Melbourne-based Psycoholgist John Boyle, on making changes and breaking habits.

   Lightbulbs went on in my head throughout the workshop, appropriately titled A conversation around compliance, motivation and the imperfect, irrational human being. Often health professionals wonder why people come to them for help, only to fail to follow the advice or treatment plan that’s provided.

   This nonsensicality begins to make sense when  the complexity of our brain, emotions and thought-patterns are accessed (and when you bear in mind that to some extent, we are in fact all imperfect, irrational human beings).

   As many of  us know breaking an old habit, is remarkably difficult. Of course there are cases where people have turned their lives around in an instant, but these are far outweighed by those of us who have tried every way to leave behind a habit, and still struggle to achieve lasting results. In fact often we can end up worse off than when we started.

   But don’t despair – some helpful tips, gleaned from John’s workshop on this topic, included:

   • When encouraging change, we must first ensure that in doing so, we don’t increase resistance to change. If we are confronted, a natural instinct is to resist, demonstrate reluctance or react. Often, objective, logical evidence is dismissed and any attempt to use logic and scientific argument can have the opposite effect that’s intended.
   • We as humans are wired to loss aversion – meaning if you told me I need to give up chocolate biscuits, I may work to avoid this. Instead it is important to focus on what I would gain from giving up that box of chocolate biscuits each day.
   • We have a commitment to our beliefs which is often difficult to terminate, even when things aren’t working. Evidence in support of a belief (such as, “no I don’t believe I need to exercise in order to lose weight”) may be lacking, but this belief has the power to create an immoveable force, leading us back to our old habits.
   • Motivational interviewing is a common and effective technique used in all forms of counselling, including dietary counseling. Instead of confronting or persuading someone to change, this technique focuses on helping a person to mobilise their values and goals so that change becomes the bi-product of this. This is done using tactics such as practicing reflective listening, open-ended questioning, and summarising – then being able to identify and act on ‘change statements’ – i.e. acting when a person is actually ready to change. Changes statements include those which; recognise a problem, show concern, show an intent to change, or show optimism about changing.

   While motivational interviewing is widely used by health professionals, I believe it can be applied to many areas of our day to day lives, and the way we communicate with each other. Without knowing it, I was constantly using this technique quite successfully when employed as a nanny. When the children resisted eating their vegetables, I would focus on what they’d immediately gain from eating them – which was having the freedom to leave the table and go and play on the trampoline again. And to a 12 year old this prospect was irresistible.

   I’d be interested in hearing your thoughts on where you think this could be applied, whether it be with your children or partner, or even with colleagues or business associates.

    

   

2. The expansion of New Zealand waistlines

   Published on Friday, September 23rd, 2011

   With the release of the 2008/09 nutrition survey summary report last week, I was heartened to read that diet-wise, New Zealand adults seem to be starting to make the right choices.  According to the survey, since 1997 we’ve reduced our overall energy fat, saturated fat and sugar intakes.  We’re eating more healthy fats and protein, fruit and selenium.  We also have lower total cholesterol levels with a better total:HDL-cholesterol ratio, potentially due to these dietary changes, but more likely due to higher rates of statin use.  A couple of interesting findings were the drop in our intakes of vitamin A, iron and zinc; possibly resulting from cutting down on full cream dairy products and red meat.

   But the real kicker is what’s happened to our waistlines, despite all this apparent healthy change.  There’s no doubt about it – we’re all getting fatter.  Sadly, as is often the case, this trend disproportionately affects certain groups in the population, with obesity rates amongst Maori and Pacific peoples in particular, starting to scale to dizzying proportions.

   While everyone agrees the reasons are multifaceted, a number of experts have provided commentary in the past week as to why this dichotomy is being seen, including (and I’m paraphrasing for the sake of brevity):

   1. “It’s because people under-report what they eat in surveys” (Rod Jackson)

   Yes, this has been documented in the literature, but in comparing like methodology with like methodology are we really likely to be recording our food intake any less accurately now than we were in 1997?  Even with an interviewer in our homes and going through our cupboards?  I’m not sure this is the only explanation.

   2. It’s partly because we’re less active than ever before and the survey did not assess activity levels.

   Certainly the basic energy in: energy out equation loop isn’t completed without an assessment of physical activity levels.  There is no question that sedentary behaviour is the elephant in the room with respect to obesity.  No matter how much we idolise our sporting heroes as a nation, the majority of us are more likely to sit on our backsides for most of the day.  Every day.  But, are we likely to be even more sedentary now than we were in 1997?  The 2006/07 NZ Health Survey found no change in regular physical activity between 2002/03 and 2006/07.  However, according to Professor Grant Schofield, our levels of sedentary behaviour are likely to be on the increase, with more hours of TV viewing, more sedentary jobs and greater car ownership/distance travelled by car in the last 15 years.  I don’t think we’ve heard the last on just how dangerous sitting can be for our health.

   3. “It’s because our environment is too jammed with easily available high fat, salt and sugar foods” Robyn Toomath.

   This is where we start to go around in circles, because the dietary intake data on the whole indicate we’re actually eating less fat and sugar.  In fact the only source of sugar which is growing in our diets seems to be fruit.  And in our fear of fat we seem to be switching to low fat dairy at the expense of retinol intakes and cutting out red meat to the expense of our zinc and iron intakes.  So are we reporting our intakes correctly? (… and the circular nature of this dicussion goes on).

   I would love to know what you make of all of this.  It would be great to get a discussion going.  Just insert a comment below (if there are no comments yet you need to click on the no comments box in order to make one).

    

    

   

3. When is a healthy recipe not a healthy recipe?

   Published on Tuesday, June 14th, 2011

   It has become the fashion for most, if not all, of our lifestyle magazines to present what they call “healthy recipes”.  This is a development that concerns me, not for the fact they are promoting healthy food, but because such recipes are generally devoid of any nutritional reference points.

   Perhaps there is an increasing demand by some for healthy, affordable meal ideas.  The unparalleled success of the Healthy Food Guide magazine would certainly indicate this. 

   As a result, everyone seems to have jumped on the bandwagon with ideas for “healthy” snacks, “healthy” pantry items and “healthy” meal ideas.  The problem is that most of these recipes do not stack up when put against real nutrition criteria, such as energy (kilojoule) content, fat content, sugar content, fibre content and salt content.  Healthy Food Guide pride themselves (rightly) on their rigorous nutritional criteria for recipes and as such, when they say “healthy”, they really do mean healthy.

   Some recent examples of other so-called “healthy” meals include anything vegetarian or gluten free, or anything our nana might have made.  While the use of a range of vegetables in vegetarian recipes is to be applauded, sadly when they are swimming in cream, oil or high fat cheeses their health benefits are somewhat offset.  One particular recent example of “healthy” has been a vegetable stack on a mashed potato base with parmesan wafers.  When analysed it was found to provide more than 75% of the daily energy requirement and more than 100% of the daily requirements of fat, saturated fat and sodium in just one serve.  The recommended serve size was also very large. 

   While there are regulations around using claims such as “low fat” on food labels, there are no such regulations covering the promotional headlines often seen on the covers of magazines.  Usually analysis of the supposedly “low fat” recipes reveals the promotional headline is outrageously misleading.

   Just as frustrating can be the use of terms such as “diet foods” – inferring healthy – but actually meaning for people (rightly or wrongly) trying to avoid particular food components such as gluten and lactose.  The recipes might be devoid of lactose or gluten, but they can make up for it with lashings of fat and sugar.

   I suspect that some of references to “healthy foods” are intended to mimick Healthy Food Guide magazine. However I suspect the success of that magazine is due not just to its strict nutrition criteria for recipes.  It’s also due to its “best friend” approach to its readership, in providing helpful, supportive ideas, while ensuring the information it provides is factually correct.   Contrast this with the claims of a recent article in a popular magazine, headlined “why sugar is making you old”.  It quotes a “celebrity dermatologist’s” theory about how sugar consumption affects the elasticity of the skin.  Any objective analysis of the published research in this field would find the evidence for such claims to be shaky, at best. 

   I have discussed this “healthy recipe” trend with other dietitians. They agree there’s a role for Dietitians NZ to provide some guidance on this, so watch this space for more information. 

    

   

4. Food Week dishes up popular cooking tips

   Published on Friday, May 13th, 2011

   There’s only 2 more days to go in the inaugural New Zealand Nutrition Foundation Food Week!

   Having completed 16 radio interviews and five interactive celebrity cooking demos with audiences of hundreds, and with 600 “likes” on the Food Week Facebook page, Sarah Hanrahan from the Nutrition Foundation is justifiably satisfied with progress so far.

   The approach of Just Cook – promoting positive, no stress cooking, with basic, inexpensive pantry essentials and just talking about food in a positive light has been received well by people so far.  “It’s so much more practical and well received than telling people what not to do”, said Sarah when we spoke to her today.

   With rising food prices and cost of living increasing, many families struggle to manage on an average New Zealand wage (as shown by Campbell Live reporter Tristram Clayton’s reality check in living on a budget), Just Cook, and its message “Just get in the kitchen and cook!” shows it’s absolutely still possible to make healthy, tasty meals in the home without breaking the budget.

   Research shows the biggest barriers to cooking at home are time, money and knowledge. Just Cook provides practical tips on how to address these barriers, such as knowing where to add a tin of beans or a cup of oats or to make meals go further for a fraction of the cost, adding good nutrition without compromising taste. The Food List  – a handy list of pantry, fridge and freezer foods to keep on hand at all times – is a great guide of kitchen essentials that can help those shopping on a budget prioritise what’s needed. And the Just Cook interactive kitchen houses easy, affordable, tried and tested recipes that cater to any combination of ingredients commonly held in NZ pantries.

   The programme also has a schools component for year 10 pupils which will be followed and evaluated in the coming weeks. Students are challenged to produce a recipe on a budget to feed a family of five, using items in the pantry list and a few extra dollars.

   As I write this, Sarah is just packing up from the final celebrity chef cooking demo in Britomart, where Masterchef finalist Nadia Lim cooked up a storm from the Food List in the fabulous kitchen provided by Fisher & Paykel. 

   You can access the celebrity chef recipes here, proof that some of our top foodies have great ideas for inexpensive food!

   We welcome any of your favourite recipe ideas or comments for making meals go further on a budget – please post these in the comments section below.

   

5. Finding new ways to bridge the food labelling debate

   Published on Tuesday, April 5th, 2011

   A new front of pack labelling system was put forward by Sanitarium today “in order to advance the discussion of front-of-pack labelling tools in the interests of promoting better public health”.

   While public health experts call for traffic light labelling (TL) and food manufacturers prefer percent dietary intake (%DI) labelling, there is no doubt that both systems have limitations.  Sanitarium is to be commended for developing an alternative concept and putting it out for discussion.  It would certainly be an extremely wonderful thing to have one system, agreed to by industry, public health and government alike.

   A brief report, outlining the system developed by Sanitarium is available.  It is clear that they have some public health heavyweights on board, with the report’s supportive foreword written by Michael Moore, CEO of the Public Health Association of Australia.

   Certainly examples of food manufacturers, public health experts and other sectors working together need to become more commonplace in order to improve the health of our communities.  It infuriates me that truly collaborative approaches are not very common (at least in New Zealand), but that’s a matter for another blog…

   It’s also very encouraging that online Australian consumer research shows that consumers find the concept easier to understand than both TL and %DI labelling.  It’s not clear whether that’s due to the single traffic light colour for each food, the fact that positive food components are included, or something else.

   Clearly the details (categories of products, nutrients included, criteria and terminologies) are still up for discussion and debate, but it’s really great to have a starting point from which to potentially develop an agreed joint approach.

   What seems to have been overlooked by the Blewett report, and others, including Sanitarium, is the well researched and comprehensive e-mark labelling system, also a viable alternative to TL or %DI labelling.  In fact the e-mark encompasses more nutritional information, is more scientifically accurate and yet is presented to consumers in a more simple way.  It also has the advantage of being less judgmental, avoiding the classic traffic light colours.  Though somehow the e-mark is just not taken seriously.  Potentially because it is not known about in Australia?   Is it the cost?  Certainly the idea of a universal system involving no fees for use, such as that put forward by Sanitarium, is advantageous.

   My fundamental concern remains with finding ways for improved knowledge to drive actual behaviour.  Internationally we are yet to see a front of pack labelling system which drives healthy food consumption.  Sadly this is because comprehension of healthy eating messages doesn’t influence actual eating behaviour.  If that were true all dietitians would have a BMI between 19 and 23 (we certainly don’t) and we would never let a morsel of “eat sparingly” food/beverage pass our lips (we certainly do, more frequently than we’d like to think).  We’re only human, and the way we all live our lives and interact with food is exceptionally complicated.

   I’d love to read your opinions about the new proposed labelling approach and any thoughts you might have about encouraging people to prioritise health over all else.  Post a comment below.

   

6. The best memories are anchored in our tastebuds

   Published on Friday, January 21st, 2011

   What’s your most memorable meal?  One of mine was a steaming hot vegetable tagine, eaten on a rooftop high in the Atlas mountains during a trip to Morocco.  It was memorable, not only because it was authentic, delicious and nutritious, but also because it was eaten in the company of good friends (and at least one local donkey), in the freezing cold, while on the holiday of a lifetime.

   Since reading Paul Thomas’s excellent feature in this week’s NZ Listener on food providing some of our best travel memories, I’ve been thinking about the significance of the food we eat.

   We use food to remember.  How many of you have a hankering for a certain dish your Mother or Grandmother used to make you as a child?  My Mum’s old custard pudding recipe is really quite ordinary by modern food standards, but it still makes my mouth water thinking about it.  The memory of it symbolises those carefree and decadent pudding-filled days of my childhood.

   Food is inextricably linked to our social lives.  It’s a key part of family life and interaction with our friends.  If I asked you to recall your most memorable meal eaten at your desk at work, or on the sofa in front of the TV, chances are you’d find it difficult.  Any food eaten in those circumstances is just fuel, and while you might feel good about it if it was healthy, you are unlikely to find it memorable.  On the other hand meals (good or bad) with friends, family or even total strangers who you’ve struck up a conversation with while eating, are far more likely to spring to mind.

   As a dietitian I see many examples of frustration from health professionals or food companies regarding how their advice/products addressing good nutrition are overlooked or not adhered to for long.  It’s hardly surprising since nutrition is not a particularly memorable component of a meal for most people.  Sadly we can’t all take off to exotic climes to eat our healthy meals in order to make them memorable and sought after.  What we can choose to do though, is to eat together more, making healthy food part of the memorable social meal equation.  I for one really enjoyed the ability to do this more with my kids more over the summer break, and as a result my oldest daughter is now requesting healthy sandwich fillings for her lunchbox for the first time ever!

   By the way, I would really like to know what your most memorable meal is.  Please share by adding a comment, and we’ll try not to get into the “one-upmanship” referred to by Thomas in his article…

   

7. en•gage•ment (in-geidj-mint)

   Published on Thursday, October 28th, 2010

   n.
   1. The act of engaging or the state of being engaged.
   2. Betrothal.
   3. Something that serves to engage; a pledge.
   4. A promise or agreement to be at a particular place at a particular time.
   5. a. Employment, especially for a specified time.
   b. A specific, often limited, period of employment.
   6. A hostile encounter; a battle.
   7. The condition of being in gear.
   Synonyms: engagement, appointment, assignation, date1, rendezvous, tryst
   These nouns denote a commitment to appear at a certain time and place: a business engagement; a dental appointment; a secret assignation; a date to play tennis; a rendezvous of agents at the border; a lovers’ tryst.

   I do believe after many years of courtship and conflict, the various groups of stakeholders in the ever-expanding waistlines of New Zealanders are finally approaching engagement.  There’s not a lot of tangible evidence of productive engagement yet, but the scene is set.

   [The cynic in me is bearing in mind that using the above definition, engagement can mean both betrothal and battle...]

   Last week I attended the popular Edgar Centre for Diabetes Research and Prior Policy Centre’s Who Cares About New Zealand’s Waistline? seminar held in Wellington.

   Much of the discussion was not new – but the format was.

   As Professor Jim Mann explains here, the event was designed to portray evidence and practice from several of the key “actor groups” previously identified by the United Nations as influencing the health of populations.  The “actor groups” chosen to contribute at this event were Food Industry, Government, Civil Society Organisations, Schools & Families, Media and Workplace.

   Researchers were asked to present the case for evidence-based action in each sector and each sector was asked to respond with what has been and what could be done in New Zealand.

   I was particularly struck by the lack of hard evidence for any one intervention within each “actor group” having a major impact on obesity rates (with the exception of better town and transport planning).  Although every group demonstrated tangible evidence that they’re doing their bit – some better than others – within each area.  And no-one can deny that the combined effect of many coordinated interventions involving many different actor groups would likely be substantial, if any such research project existed to provide the hard evidence.  Presently it’s an ambitious dream, but monitoring action and research in this way on an annual basis will hopefully show progress.

   Tariana Turia impressed us all with her personal and compassionate concern for the issues.  You can read her speech here.

   Professor Grant Schofield from AUT was bold enough to admit that people don’t want to hear public health messages.  He suggested we need to re-frame the problem/issues into solutions/benefits/outcomes our audiences can relate to.  This was also backed up by sentiments expressed in the media session by Lorelei Mason and Jim Tully about what consumers want.

   Re-framing the issue is something done particularly well by the private sector.  Engaging in marketing and business tactics used successfully by the private sector are exactly what could make the difference to public sector campaigns.  In a recent inspirational TED presentation by Melinda Gates, she stated (of the need for aspirational marketing in health) “…<health agencies> assume when people need something we don’t have to make them want it”. It’s very true.

   Which brings me back to the need for real engagement between all actor groups to engage New Zealanders in the issues.  The main point I took from the research outcomes presented was that working away diligently in silos is not likely to trim our waistlines one iota.

   Well done to Professor Jim Mann and his team – who did a lot of the legwork to pull together the programme.  It was a refreshing approach.

   

8. The resurgence of ‘Home Grown’

   Published on Thursday, October 14th, 2010

   Growing fruit and vegetables at home is hardly a new phenomenon. But over the past couple of years there has been a real surge in popularity of home grown produce. It’s been reported that in response to the Global Financial Crisis, the popularity of home gardens has risen in some areas of New Zealand by up to 22% and this trend now is extending far beyond our own backyards.

   The advantages of home grown produce are being recognised across the world. A recent survey of 2000 American chefs found one third of them identified restaurant gardens as the most popular trend for 2010. Not only does restaurant-grown produce cost less, but more and more of their customers want to know where their food comes from, and what better way to show them than to take them out to the restaurant garden?

   An example closer to home of this resurrection, is the Garden to Table pilot programme, which started in several Auckland schools last year. The programme aims to teach children to grow and harvest produce and prepare meals using what they’ve grown. It was modelled on the Stephanie Alexander Kitchen Garden Programme – Stephanie Alexander is a pioneer in food education for children and is visiting Auckland later this month.

   The Enviroschools network, which works with one quarter of all schools and kura in New Zealand, has empowered schools to plant their own gardens, as part of their focus on “nourishing our natural systems” since the late 1990s.  It’s been wonderful to see schools across a range of deciles getting involved, and now the Garden to Table project is closing the loop by also bringing in cooking skills. Along with teaching children gardening and cooking skills which can be taken home, the children are given the opportunity to enjoy sharing meals with their classmates, teachers and volunteers, and enjoy the social time that comes with sharing a meal – something that is equally important in developing lifelong healthy attitudes towards food.

   The resurgence of home grown produce can only be a positive thing, both for the environment, our communities and hopefully our waistlines. However, we mustn’t feel guilty about purchasing fresh, canned or frozen fruit and vegetables from the supermarket.  For most of us this is still a necessity, especially for produce the average home gardener would be challenged to have on hand year-round!  It’s also important to take a practical attitude towards growing produce and plan ahead to ensure you can use what you grow.  My flatmates and I created a vege garden last year, but just as all our produce flourished, we went away on holiday. By the time we got back, our broccoli had flowered and our herbs had been attacked by slugs!

   If you don’t have access to home grown produce, the next best thing may be the hundreds of fruit trees and other edible morsels dotted on public land throughout New Zealand! Check out the map to find the nearest one to you!

   

9. I’m sceptical….what are you?

   Published on Thursday, July 15th, 2010

   New Scientist ran an interesting series of articles about denial in May this year.

   It got me thinking that scepticism vs denialism is another way of describing a theme often addressed in this blog.  I consider myself a sceptic – meaning that I take an objective approach to the evaluation of claims – but I also find that a bit of commonsense goes a long way.  Deniers, on the other hand, have a position (or end goal) staked out in advance, and sort through the data employing “confirmation bias”.  This is defined by New Scientist as “the tendency to look for and find confirmatory evidence for pre-existing beliefs and ignore or dismiss the rest”.  Whether sceptics agree or disagree, we can debate the issues like grown ups.  Dealing with denialism feels more like trying to rationalise with a toddler having a tantrum.

   It’s easy to think of denialism as an old fashioned notion, driven by zealots such as anti-evolutionary theorists or those who believed the Earth was flat.  But no – denialism is alive and well in our modern world.  We’ve all heard of climate change and vaccination deniers.  New Scientist provides useful perspectives on these examples, as well as deniers of the ill health effects of tobacco, the existence of AIDs and those who believe pandemics such as swine ‘flu are developed and released by pharmaceutical companies.  I can add more examples to this list based on personal experience in the food and health area.  Those who are convinced that:

   • obesity is caused by single foods or beverages (and that this is a conspiracy of global food companies).
   • anti-tobacco tactics directed to certain foods are the best option to combat obesity.
   • specific approved food additives or ingredients cause illnesses ranging from autism to cancer (and that this is a conspiracy of both food companies and food safety organisations).
   • there are no adverse health effects of high salt diets at a population level.
   • it’s acceptable to deliberately design research studies to prove a point or handpick research results to suits their means, rather than taking a more objective view.

   Your typical denier often has the public’s sympathy because they’re the “underdogs, fighting the corrupt elite”.  They often occupy the moral high ground for this reason.   And the media love the extreme viewpoint they offer so they have a natural public stage.  Regulators, businesses and governmental organisations do not have the luxury of being able to handpick evidence to suit.  They have to be objective, so they often come off looking non-committal, or at worst, defensive, when facing denialists in public.

   In my digging around for material on this subject I also found this delightful quote by Richard Asher, published in The Lancet in 1959.

   “It is important to realise that ideas are much easier to believe if they are comforting and that many clinical notions are accepted because they are comforting rather than because there is any evidence to support them. Just as we swallow food because we like it, not because of its nutritional content, so do we swallow ideas because we like them and not because of their rational content.”

   I believe this rings especially true today and I’d love to hear some more examples of denialism that you’ve come across.

   

10. All hail the cheese roll

    Published on Thursday, June 17th, 2010

    They’re celebrating and exploring the science of the cheese roll in Dunedin this month.  I love cheese rolls, and reading about this makes me want to rush home and cook up a batch of these warming winter treats.

    Winter food is all about comfort, warmth and sustenance.  Soup is a great example of this (and a perfect food match to those cheese rolls!).  All those great staple classics like lasagna, shepherds pie, macaroni cheese and casseroles come into their own at this time of the year.

    For those from the southern end of New Zealand, the humble cheese roll is so much more than a tasty snack.  It’s part of our heritage.  It’s about memories of Grandma and family times.  It’s about sharing with friends and social occasions.  And for those north of the cheese roll divide, there are other food favourites which fulfill this role in life.

    The powerful social role of food cannot be underestimated.  Recently I read some consumer research showing that the majority of people prioritise good nutrition when choosing what to eat at home or in routine situations.  But unsurprisingly when asked the same question in relation to times when they’re socialising or eating with friends, good nutrition became less of a priority.

    When communicating about food and nutrition the power of food’s traditional social role in our lives cannot be underestimated.  These messages mean very little if they fail to acknowledge people’s behaviour and feelings around food, especially in social settings.  Excellent nutrition communication needs to provide ways and means of achieving the same warm fuzzy feelings around healthy eating.

    And for those of you who’re dying to experience the magic of the Southland Cheese Roll to warm you up this winter, here’s a great recipe.