The current fad is no exception.  I took this photo in my local book shop this week, and you’ll see that the recurring silver bullet today is cutting out sugar. It seems we’re lining up in droves to buy these books, judging by the amounts stocked in bookshops.

As a dietitian who works with food industry clients, including a sugar company*, I know quite a bit about the role of sugars in our diet, our intake of sugars in New Zealand, and the evolving scientific consensus involving sugars and health. So this diet fad is keeping me pretty busy as I try to inject some New Zealand context and scientific evidence into the space.

Let’s be clear, I’m not advocating for unrestricted sugar consumption, or arguing that sugar is particularly good for you.  Advice relating to sugars is, and always has been, relevant to strategies to reduce the high risk of overweight and obesity in many countries. However, a singular focus on sugars is unwarranted and would be ineffective for the wider population, when there is nothing metabolically special about sugars (over any other energy source) to cause weight gain.  This singular focus also distracts from the importance of a person’s whole diet, and may unintentionally reduce diet quality by reducing intake of nutritious foods such as fruit, vegetables and milk, and increasing intake of saturated fats.

In 2010 an Australian nutritionist, Dr Chris Forbes-Ewan, provided this useful and balanced feedback on one of the books pictured above.  The points he made are still just as relevant today, and I could not put them better myself.

My own personal advice on sugars is pretty simple – ideally items high in sugars should either; also contain a lot of other essential nutrients (vitamins, minerals, fibre, phytonutrients) to justify their regular consumption; or be enjoyed in small amounts.

I used the word enjoyed deliberately. Food is more than a collection of nutrients. We are social beings who interact, share, love and dream over food.  Without the ability to enjoy food (responsibly) life just isn’t much fun.

To justify their investment, some of those on these fad diets claim all sorts of short term health gains. I’ve even been approached by “believers” suggesting that all dietitians should provide this advice to their clients, because a number of general practitioners are promoting it.  With all due respect to general practitioners, nutritional science isn’t generally their area of expertise.

While I applaud the “believers” for changing their lives, there is no evidence that the responsible consumption of sugar caused their initial health problems.  Frankly, cutting any common source of dietary energy from  your diet altogether will drastically reduce overall energy intake.  Simply being conscious of (and thereby restricting) what you’re putting into your mouth is known to result in weight loss to start with.

Unfortunately the long term results on weight and micronutrient status are unknown – generally because people can’t stomach fad diets for very long.  That’s what makes them fad diets.  But not to worry – the astute authors will have dreamed up another fad diet to make their money from by then, and so the rollercoaster devoid of common sense continues…

*this blog represents my own personal views, not those of my clients.

The reason our supermarket foods don’t carry more foods with the label, “Product of New Zealand”, is that they don’t exist. Basically the reasons boil down to the inability to grow many ingredients, a tiny domestic market, and a lack of  investment which results in a lack of scale and an inability to meet competition from imports.

Strange as it may sound, it is the consumer who’s in the driving seat when it comes to determining the origin of their food products through purchasing power, irrespective of what growers can produce and food companies might make.  This is aside from items that we simply  or don’t grow on a commercial scale, like one of the largest selling fruits, bananas.

Consumers make their choices about what they buy in a supermarket, and price plays a major part on their decision making.  It’s true that brand and taste still figure very prominently in the purchasing equation, but for more and more consumers, price is the deal maker. We’ve seen this recently in Australia where local production  lost out to less expensive imports.

The reality is that in a tiny domestic market like New Zealand, very few companies have the scale to buy ingredients and prepare foods that are price competitive with imported food products, which now more than ever have the benefit of a high New Zealand dollar.

For a product on the supermarket shelf to be competitively priced, means that the ingredients have to be competitively priced and production has to be cost efficient.  So it is not only a question of whether an ingredient is available in New Zealand, but whether it is available on a commercial scale and at price that allows the finished product to be competitive.  This includes flour for commercial scale bread making.

Some try to fight imports by maligning the country of origin, because they have the mistaken belief that everything grown and produced in New Zealand is safe, and everything grown elsewhere is not. More important is the guardian or brand of the food, and the reality is, regardless of whether a food item is made locally or imported, it must meet the very same strict standards of food safety.

Likewise, some are confused  by the labelling of foods with “made from local and imported ingredients”. Often this is without any thoughts as to what those ingredients are. Take Wattie’s Baked Beans. Despite a number of attempts over many years Wattie’s has not been able to establish a local supply of navy beans.  There has been no lack of willing, it is a matter of having the right bean for local conditions. Again, take Wattie’s Spaghetti. The spaghetti pasta is actually made Hastings, but the flour is imported because there is not a viable local supply for this product.

There are many food products that include ingredients not available in New Zealand. For instance, all our sugar and rice is imported because there are simply no local supplies.  The same with many herbs, spices and oils.  The reality is that neither home cooks or food manufacturers would use pricey gourmet olive oil, such as NZ produces, every time oil is required in a recipe.

Week after week books are published and media reports are issued focussing on finger pointing.  For the past six months in particular all fingers have been pointed at the food industry – in particular the “food giants” – for manipulating and addicting consumers to their products.  Prior to that – at least in New Zealand – experts have pointed to Government, for their lack of investment in preventative health and unwillingness to introduce regulatory taxes, bans and restrictions for certain foods and food marketing.  And any health-related association or sports group is now being criticised for working collaboratively with food companies because of the fear that food companies only associate with health-related associations as a fluffy PR exercise. It is not known what foundation there is for such fear, but it’s enough to make food companies throw in the towel on their numerous attempts to introduce healthier options and reformulate existing products, and just start doing exactly what they’re being accused of (if people are determined to think that anyway).

In the meantime is the population any better off?  When the average person spends less than a second deliberating over their supermarket choices and juggles food provision for their families with all of the other priorities in our busy lives, what is all this finger pointing achieving for them?

I would venture to say it’s doing more harm than good.  It’s causing even more confusion.  The bottom line is people have to eat and drink something to stay alive.  Dietary experts and food and nutrition guidelines largely make recommendations based on the four food groups, which actually don’t relate well to what the average person has to choose from when they’re in the supermarket or eating out these days. People also don’t have the lifestyles or incomes that enable them to grow their own foods or shop at farmers markets (wonderful as they are).  They simply buy and eat what they like/can afford/are familiar with – in that order.  So achieving the shift that motivates them to also vitally include in the purchasing mix “know is healthy for them” requires the following:

- Unity and clarity in scientific advice from Government and academics which relates to the current food supply, not the foods which Nana had to choose from when she shopped for her family back in the 1960s.

- No more contradictory, confusing, subjective and unsubstantiated messages or blanket statements which only result in people giving up and going back to what they know and like.

- Support and endorsement from the scientific/health community when food companies make positive nutritional changes, so that there is actually a demand for healthier products from the population.

- Dropping the blame game.  Truly collaborative implementation of solutions is the only way forward to deliver real benefits to the population.  This will involve significant compromise for all parties, who must commit to concrete actions and be held accountable to those in the long term.

Can’t we just get on with it?

Is food addiction the ever-elusive single cause of the obesity epidemic?  As a slightly pedantic sceptic, I must admit to finding this term somewhat illogical.

The official definition of addiction is: a persistent, compulsive dependence on a behaviour or substance.  To some degree aren’t we all persistently, compulsively dependent on food?  After all, unlike nicotine, gambling, alcohol and narcotics, we cannot live without it.  Preferably we need it at least three times a day, every day, for our whole lives.  Yet only a third of the population are supposedly at risk of having “food addiction”.   If broccoli was your preference, would that be labelled an addiction?

Don’t get me wrong – I’m not trying to belittle the justifiably valid concerns of those who feel completely out of control around food, and who legitimately see this as a reason for their own weight problems – I just don’t see these people being in the majority.  I was intrigued when I recently saw a notice on a bus advertising an Overeaters Anonymous meeting.  Perhaps this is something we will see more of, and hopefully, as with AA, it will be a very helpful framework for individuals in order to work though common issues towards recovery.

But does this loss of control around food (or more correctly, specific types of food) occur in isolation?  I’m no psychiatrist, but it would seem to me that underlying reasons for this type of behaviour would be multifactorial and complex.  Overeating is therefore a symptom, which sadly results in symptoms of its own, exacerbating a cycle of health problems.

I don’t think the complete loss of control around food, with a continuous drive to eat more and more around the clock is solely responsible for the obesity epidemic we face.  Most of us eat a little too much on a regular basis and are too inactive to balance
this intake of calories.  Over time this leads to a gradual increase in the waistline, until we are in a situation where more people are overweight than are normal weight within the population, and nearly the same proportion are obese.

If it helps people to examine what they’re eating and how active their lifestyle is to label themselves as a “food addict”, then so be it.  The only outcome I’m interested in is people getting healthier.  This involves solutions that enable all of us to take more ownership of our health and make wiser choices about what foods and drinks we choose to buy and consume, in what amounts, and how much we sit being inactive.  What do you think?

Image thanks to FreeDigitalPhotos.net

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.

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.

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).

As a nutrition communicator I spend much of my time trawling the pages of PubMed, tapping away on the computer, laptop, iPhone or iPad, using social media and other electronic networks to share balanced, evidence-based food and nutrition information.  It was actually quite a relief to rest my thumbs for a few days and use my own voice and ears instead.  So much so that I now sound like a pack-a-day smoker!

Together with Sarah (a colleague from the NZ Nutrition Foundation) we presented a social media workshop for dietitians at the conference, and while we were very successful in convincing New Zealand dietitians to jump onto the blogosphere, I was surprised at how much the experience reminded me that social media is only useful in-between times of face-to-face contact.  In fact when I think about it, the dietitians I interact most with via social media networks are the ones I’ve actually met in person.

Is it a generational thing? Being someone who grew up without the internet, who can even remember what working-life was like prior to email, perhaps I’m biased?  Are you more likely to respond to questions and take part in social media discussions about professional issues when you’ve actually met the person seeking input?  I guess I’ll get my answer from your comments below…