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The universal call to increase the consumption of fruits, vegetables, higher fibre foods and seafood, coupled with tightening family budgets, means that a study published recently in the Journal for Nutrition and Food Sciences is highly relevant.

The study looked at the nutritional qualities and relative cost of canned foods, and reassuringly found that canned foods provide sound nutrition at an affordable price, in a convenient format.  Specifically much-needed key nutrients, such as fibre, protein, folate, vitamin C, and vitamin A were shown to be significantly preserved in a range of canned foods.

The nutritional findings are in line with research undertaken here in New Zealand about 10 years ago, but the latest study went an extra step by evaluating affordability on a price-per-serve basis against fresh, frozen and dried counterparts.  The affordability measures took into account preparing and cooking time, and also energy usage.

The study looked specifically at canned beans, corn, mushrooms, peas, pumpkin, spinach, tomatoes, peaches, pears and tuna; comparing then with their fresh counterparts.

Two examples of the findings were:

• Tomatoes – It is nearly 60 percent more expensive to obtain dietary fibre from fresh tomatoes as from the same portion of canned tomatoes.
• Corn – When looking at purchase price alone, fresh corn is less expensive than canned or frozen. However, when the cost of waste (most notably the cob) is factored in, as well as time to prepare, canned corn offers the same amount of dietary fibre with a 25 percent cost saving compared to fresh and the same amount of folate with a 75 percent cost saving compared to fresh.

The NZ Nutrition Foundation (NZNF) commented on the relevance of the findings, as they come at a time when many families are struggling to put healthy food on the table because of limited budgets. It also makes the point that canned foods ensure essential nutrients are more accessible to consumers, particularly those with limited storage, preparation facilities, limited time, skill or interest in preparing fresh foods.

I find this heartening, at a time when so many of our current foodie programmes put great emphasis on the use of fresh fruit and vegetables.  I fear this may be setting the bar too high for many kiwi families who are struggling to make ends meet.  We now know that canned foods do deliver the goods nutritionally and needn’t shy away from the limelight, in the informed kitchen.

It was a great opportunity to show what is happening in NZ and how we as a nation are faring in these tricky times and what the food industry and health sector are doing to address a global issue.

Not surprisingly, but no less disappointingly the piece was fairly one dimensional and single-mindedly focused on sugar and soft drinks.  What it did highlight, once again, was the limited lens through which so many people choose to examine the link between food and health, or rather food and disease as appears to be the main focus.

While I commend Sunday for attempting to help New Zealanders think about what they choose to eat (or in this case drink), the facts do not warrant the dramatic way in which this, and many other stories are presented.

It certainly makes for good TV to show a wheelbarrow full of sugar to represent how much we each consume annually, but this is somewhat misleading.  Likewise we each consume several Olympic-sized swimming pools of water annually, which also looks frightening.  In fact on a daily basis our median intake of sucrose when last measured in 2008/09 was just 48g.  And it’s on the decline (it was 53g in 1997).

Also, only 5% of our energy (as measured in 2008/09) came from non-alcoholic beverages.  And just 1.4% of energy was contributed by the sucrose in all non-alcoholic beverages (only part of which is sugary soft drink).  The rest, presumably, is contributed by fat, lactose, fructose, glucose and protein (remembering this group includes all non-alcoholic beverages other than plain milk).  So are the other foods and drinks which contribute 98-99% of our energy intake unimportant?  I think not.

In New Zealand, our intake of sugar (and particularly sugary soft drinks) differs significantly from countries like the United States, where much of the concern about sugar intakes stems from.

I don’t wish to trivialise the issue, as clearly the above figures are population medians, and some New Zealanders do over-consume.  I would like to propose however, that these individuals are unlikely to be over-consuming on sugary soft drinks alone, and are more likely to be part of the growing number of food-illiterate people who don’t understand what over-consumption is.

To Professor Rush’s point, there is some evidence that we feel less satiated when we drink kilojoules, compared with when we eat them (because our stomachs empty more quickly), but I think the issue of satiation is far broader than just blaming drinks for our obesity problem.  More and more New Zealanders seem to have become so accustomed to constant grazing on food and drink, to the point that many do not recognise the feeling of satiation, let alone the feeling of hunger.

What drives us to this?  Economic, cultural and social issues that shape the environment we live in and the choices we make.  Recently I read some research which found that most people no longer know what a calorie/kilojoule is.  Yes, sugar and sugary drinks provide kilojoules, but so does everything we eat.  In order to improve our health as a nation, individuals need a basic understanding of their own diet and how it relates to their own health; they need tools to help them make the best choices for them individually and they need to accept some individual responsibility for what they feed themselves and their families on a daily basis.

Yes, I do provide independent nutrition advice to a range of food companies, including NZ Sugar and Coca-Cola Oceania, so you may think my opinion is biased.  As a result though, I’ve been following this issue closely and am aware of the evidence, plus lack of evidence, surrounding it.  In my experience, it’s hard to get those without a vested interest in this issue to speak up – at least in New Zealand.  My personal view is to stick to the facts, and to address all of the issues with practical solutions, rather than pinpoint one possible contributor alone.  If there was a single silver bullet to address obesity, we would have found it my now, and we’d all be an ideal BMI.

Lessons from this ancient fable are just as relevant today when we evaluate how various scientific experts approach the totality of scientific evidence.  Recently we had a good example of this when one prominent scientist published his professional (and somewhat extreme) opinion on sugar in Nature, resulting in a media storm and “expert” slanging match across the globe.  Personally I thought Dr Arya Sharma’s commentary on this was one of the better ones.

The very essence of scientific endeavour is to prove or disprove hypotheses, and since research often raises more questions than it answers, further research is usually justified.  So individual researchers passionately chase logic down the path where their research leads them.  It’s hardly surprising that when they come up for air and see what other “descriptions of the elephant” exist, debates can get heated. People who “describe the animal in the same way” comfortably reference each other’s material, while desparately trying to disprove the findings of others who might describe the animal differently.  Hence many highly esteemed experts fight it out in the media and the general public become more confused and disenchanted than ever.

In the world of nutrition science nothing is black and white, as everything is highly dependent on a complex web of lifestyle variables and genetic make-up.  It is therefore difficult to make clear and meaningful recommendations on a population basis, and no wonder really that we usually wind up back at use-your-common-sense messages, such as “eat a variety of foods” and “a balanced diet” which can be waffly and confusing for people.

White hat scientists (and there are a lot of them), tend to take the approach that it won’t do anyone any harm , rather than the evidence-based approach.  There is an increasing school of thought that goes; since it takes so long to prove or disprove scientific theories on nutrition, we should just make recommendations which may not be effective but can’t do any harm.  The American Heart Association clearly states in its position paper on sugar that “research tools thus far have been insufficient to confirm a direct link” [between added sugar intake and weight gain]. Then they go ahead and make  prudent recommendations anyway.

Sadly this well-intended advice often serves to confuse and alienate the public further, as they reach for another chocolate bar and vow never to listen to another expert.  Judging by the comments on TVNZ’s Breakfast facebook page (Feb 24th) this is certainly what happened when the NZMJ published a viewpoint article listing 49 foods for obese people to avoid, and the media made a complete meal of it.  Yet again, the dietitians among us come out of it looking like the food police.

So, can we win?  Is practical, meaningful and evidence-based dietary advice the ever-elusive holy grail?  I’d love your views on this.

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).

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. 

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.

The main point Haub’s trying to make is that if energy in (no matter what the source) is less than energy out, you will lose weight.

Fair enough point, but he also wants people to question the idea that eating fruits, vegetables, low-fat protein and whole grains is the only way to lose weight, saying:

“It’s unrealistic in some areas of society to expect that you can find fresh broccoli, tomatoes at a price that is affordable.  If somebody can get their nutrients from a supplement and then they get their fuel from whatever is available, does it matter that they’re not getting fruits and vegetables and whole grains?”

Call me old-fashioned but I find this far less easy to accept.  I note the ‘fine print’ of his experimental diet does include some plain vegetables for nutrients and milk for protein.

On the other hand he does have a point; the affordability of healthy food is a key issue.

At the Dietitians NZ conference recently there were numerous discussions and media attention on “food stress”.  That is the stress caused by food insecurity and the affordability of healthy food.  Access to, availability of, and even knowledge around healthy food is not the issue for low income households.  The real issue is the need to spend up to a third of their weekly income on purchasing a basic “healthy food basket” – which is simply not affordable on a low income.  This explains why filling, cheaper, and invariably higher energy, low nutrition density foods are more popular with low income households.

It makes you wonder how ethical current healthy eating messages really are for the very groups who seem to need them most.  Price discounts on healthy food may work in the short term (as seen in the SHOP study), but, even this study indicates that over time, the effect starts to wear off.   A simple solution could be the current call to remove GST from “healthy foods”, but we simply do not know whether this will have the desired long term effect on consumption patterns.  Anecdotal information from Australia would indicate not.

The experts agree that we don’t have enough research to provide answers, but in the meantime what should be done?  Should temporary rolling price discounts on “healthy food basket” items be made mandatory?  How would this work practically? I’d love to hear your views on this.

The interface between science and journalistic endeavour is an area of constant tension. Rarely does a singular study change the course of knowledge. This comes about by the gradual accumulation of a body of evidence, each study with its own strengths and flaws.  And for every five studies that prove a point there are bound to be at least four which disprove it, or vice versa.

It’s an unfortunate truth that cumulative evidence over long periods of time is just not attention-grabbing material.  Nevertheless that’s what forms the basis of evidence-based recommendations such as the food and nutrition guidelines.

Meanwhile it’s frequently opinion, and our propensity for storytelling which creates human interest and media attention.  Regrettably at times it is presented as fact.

By way of example, I’d like to share a recent frustration with one of our daily papers.  A few weeks ago there was a large, well-meaning, colourful feature about the sugar content of popular children’s breakfast cereals.  The headline  described them as junk food.  My concerns about this article were multiple:
1.    The sugar content of cereals is hardly news, when every single packet, by law, displays the sugar content per 100g.
2.    The sugar content per 100g is really only useful when comparing between cereals in the supermarket.  It does not equate to the sugar content per serve, which in this particular case would have been about a third of that colourfully highlighted.
3.    A public health advisor contributed: “cereal manufacturers use layers of sugar on fat on salt on more sugar to get people hooked on the product”.  So,  you could be forgiven for thinking that breakfast cereal – surely a good product to develop a life long habit for – is less preferable than sending little Johnny off to school on an empty stomach, or with a belly full of bacon and eggs.
4.    There wasn’t any information which would help the average person to put the sugar content of these possible breakfast options into context with other possible breakfast options.  I don’t know any children who’d be happy to eat weetbix or porridge without sugar or fruit, which would essentially render either of these options equivalent in total sugar to most of the cereals listed in the article.  Unfortunately the other recommended option,  “homemade bircher muesli” requires a luxury of time that most of us don’t have, not to mention it being made with fruit juice, grated apple and yoghurt, adding a substantial amount of sugar.

So the average Mum (household shopper) is left feeling guilty (yet again) for feeding her children something they will actually eat for breakfast, and has no idea what she should replace it with.

But she only has to wait a week before another article from the same paper gives her a solution.  This extols the health benefits of maple syrup and encourages parents to drizzle it over their children’s breakfasts for “nutritive value”.

And we wonder why people get confused….

If you have any similar examples to share I’d love to hear them! Just submit a comment below.

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.

In olden day cowboy movies the do-gooder cowboy heros wore white hats.  Recently the term “white hat bias” was coined to describe bias in scientific research on obesity (the subject of much nutrition research at present) which leads to “distortion of the published information in the service of what may be perceived as righteous ends”.

A commentary in this month’s International Journal of Obesity discusses this phenomenon and analyses examples.  Particular bias on topics related to weight, nutrition and the food industry were shown, especially a tendency to distort information about products such as sugar-sweetened beverages or practices like breastfeeding, regardless of the facts, when the distortions are perceived to serve good ends.

The authors examined the areas of citation bias, publication bias miscommunications in press releases and the inappropriate or questionable inclusion of information.  Analysis of specific research papers in the areas of reporting effects of sugar-sweetened beverages on body weight and the protective effects of breastfeeding were included.

The analysis showed that less than one-third of the papers citing the beverage studies accurately reported the overall findings, and more than two-thirds exaggerated evidence that reducing sugar-sweetened drink consumption reduced weight or obesity. The researchers also found several examples in breastfeeding studies in which the white hat authors selectively included some data and discarded other research to support the theory that breastfeeding decreases the risk of obesity.

For both the beverage and breastfeeding research, the resulting data was more likely to be published when it showed statistically significant outcomes. Studies with outcomes that did not show sugar-sweetened drinks to be bad and breastfeeding to be good were less likely to be published.

Notably, this bias appeared in studies not funded by industry, raising questions as to the motivation on non-industry funded research.  Interesting; since for many years health lobbyists have also sought to disqualify the results of industry-funded research.

Some researchers like to demonise certain products or defend practices with a kind of righteous zeal.  Whether this is intentional or unintentional, it’s simply wrong to stray from truthfulness in research reporting.

So, perhaps with the best of intentions, scientists are actually distorting the available evidence and losing sight of what science is about – the disciplined, objective observation, collection and documentation of findings.  The authors refer to white hat bias as “eroding the foundation of scientific discipline”.

Last week I went to a seminar in Wellington which discussed similarities between the food industry and tobacco industry, and was reminded of the potential dangers of White Hat bias being used here in New Zealand.

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