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This month’s San Francisco Chronicle column evolved in answer to a question from a former colleague at the UCSF School of Medicine.

Q: What do you think doctors should be telling patients about how best to care for themselves and their families, nutritionally?

A: I had my chance when, long ago, I ran a nutrition education program for medical and other health professions students and practitioners at UCSF.

Then, as now, it was obvious that just about every patient who landed in the hospital needed nutrition intervention. Practically everyone who visited the outpatient clinic either wanted or needed nutrition advice.

Then, as now, few doctors were taught anything about nutrition, let alone the details of what they needed to know to help patients address dietary concerns.

In today’s health care environment, even doctors with advanced nutrition training do not have time to use it. Blame this on how our health care system systematically rewards doctors for treatment of disease, not its prevention.

What doctors need to tell patients about nutrition depends on who the patients are. If people are sick, doctors need to talk to them about how dietary changes and improvements will help them recover and prevent further illness.

But I’m guessing that your question refers to healthy patients who want to stay that way. With these people, what doctors do and say can have profound effects. Doctors are authority figures and their advice is taken seriously.

As a standard part of patient care, doctors routinely ask about drugs, cigarettes and alcohol. Even if they only have a minute, adding one more question about diet can do much good. If nothing else, it conveys that diet matters to health.

Given the reality of time constraints, my wish list for what to do next is necessarily short.

Tell patients that healthy eating simply means three things: variety, minimal processing and moderation.

Variety means choosing many different kinds of foods from the various food groups: meat, dairy, fruits, vegetables, grains. It counts because foods vary in nutrient content. Varying foods within and among food groups takes care of needs for nutrients without having to think about them. People who consume adequate amounts of varied diets rarely exhibit nutrient deficiencies. It’s the most restrictive diets that are likely to be deficient in one or another nutrient.

Minimal processing means that the foods should be as close as possible to how they came from the animal or plant. The greater the level of processing, the less the foods resemble their origins, the less nutritious they may be, and the more salt, sugar and calories get added to disguise the changes.

Minimal processing excludes foods high in salt and sugars and low in fiber, as well as sugary sodas and juice drinks, those popularly known as junk foods.

My definition of minimal processing is only slightly facetious: Don’t eat anything with more than five ingredients or an ingredient you can’t pronounce.

Moderation is about balancing calorie intake with expenditure and maintaining a healthy weight through food choices and physical activity.

These are general principles. Beyond them, nutrition advice must be personalized to the particular individual or family. To do that quickly:

• Ask patients what they and their children eat. You can start with a waiting-room questionnaire that probes typical intake of foods and supplements.
• Screen the responses for variety, minimal processing, moderation and excessive or unusual supplement use. Note whether body weights are within healthy ranges.
• Reassure patients whose diets are varied, minimally balanced and moderate that they are doing wonderful things for their health and should keep doing what they are doing.
• Refer observations that need further discussion to a nutritionist.

Doctors: You don’t have to do it all. Making it clear that diet matters is often enough to encourage patients to make better dietary choices. Use the services of a nutritionist. Nutritionists are professionally trained to answer patients’ questions about diet and health and to counsel them on dietary interventions.

Patients (meaning everybody): Tell your doctors that you want their advice about diet and health and expect them to know something about it.

How can food producers become more sustainable? Use less meat in their products.

Rita Jane Gabbett writes today on Meatingplace.com, a meat industry site, about a talk given by Cheryl Baldwin of Green Seal at a recent meeting of the Institute for Food Technologists.

She told Meatingplace that meat producers should better understand “the production methods used to feed and raise animals, making sure they are treated humanely and looking for ways to reduce the carbon footprint of processing methods.” She also said that “grass-fed animals created a lower carbon footprint than those that were grain fed.”

One can only imagine the reaction of meat producers to her comments.

Meatingplace noted:

Earlier this year, however, a study by the University of New South Wales published in the journal Environmental Science and Technology indicated beef produced in feedlots had a slightly smaller carbon footprint than meat raised exclusively on pastures. (See Feedlot beef could be “greener” than grass-fed: study on Meatingplace, Feb. 8, 2010.)

More recently, Washington State University scientists concluded that improvements in U.S. beef industry productivity have reduced the environmental impact of beef production over the past decade. (See Better beef industry practices have reduced carbon footprint on Meatingplace July 15, 2010.

This follows soon after the Dietary Guidelines Advisory Committee report’s advice to:

Shift food intake patterns to a more plant-based diet that emphasizes vegetables, cooked dry beans and peas, fruits, whole grains, nuts, and seeds. In addition, increase the intake of seafood and fat-free and low-fat milk and milk products and consume only moderate amounts of lean meats, poultry, and eggs.

To the meat industry, advice about health and sustainability must come as a serious challenge. Keep an eye on the “eat less meat” theme. My guess is that we will be hearing a lot more about it.

The Dietary Guidelines Advisory Committee held a hearing yesterday on its recent report (see my posts of June 28 on the politics of this report, and June 29 on its science).  I could not attend the hearing but am collecting second-hand reports from people who attended or testified.

Philip Brasher, who blogs at GreenFields.com, summarizes lobbyists at work:

• National Pork Producers: “Lean meat is a vital source of high-quality protein and certainly should not be framed as a food to limit in the American diet….Urging Americans to shift to a more plant-based diet and consume only moderate amounts of lean meat implies they should decrease consumption of this vital, complete protein.”
• Egg producers: “The average American could increase egg consumption and still be within the egg-a-day limit.”
• The Sugar Association: Advice to reduce sugar is “impractical, unrealistic and not grounded in the body of evidence.”
• The Salt Institute:  “Encouraging consumption of low-salt foods will encourage Americans to eat excessively to make up for the lack of taste….The guidelines have become far more a reflection of ideology than sound science.”

The Organic Trade Association testified that the scientific review, which found no significant nutritional differences between organic and conventionally produced foods, is:

Neither grounded in current science nor relevant to the mandate of the Dietary Guidelines….[it is] in direct conflict with the advice put forth by the recent President’s Cancer Panel report regarding ways to reduce environmental cancer risk….It is inconceivable and alarming that the very document that is the underpinning of our nation’s policies regarding food and nutrition would include a statement that directly contradicts these recommendations….As released, the guidelines confuse the consumer, contradict the President’s own Cancer Panel, and do not enhance dietary recommendations.

To repeat: The committee report is simply advisory.  So is the lobbying.  The sponsoring federal agencies, USDA and DHHS, now must deal with both as well as with written comments on the report’s statements and recommendations.

The agencies write the final guidelines. Will they include advice to cut down on added sugars and fatty meats?  Will they say anything positive about organic foods?

Maybe, if enough people weigh in with such opinions.  Comments are due by July 15.  Here’s how.

Addition, July 10: Amber Healy’s terrific account in Food Chemical News (July 12) summarizes the hearings as “largely boiling down to a single question: Is meat good or bad?” For example:

• People for the Ethical Treatment of Animals, the Physician’s Committee for Responsible Medicine (PCRM), the Soyfoods Association of North America and Christina Pirello, the host of a cooking show on PBS: the guidelines should more clearly spell out the benefits of reducing meat consumption and take a stronger position on the need to reduce intake of processed meats.

• Sally Fallon Morell, president of the Weston A. Price Foundation: the recommended reduction in intake of lean meat and protein from animal sources could “perpetuate the kind of nutrient deficiencies” that the guidelines try to avoid and even lead to lower fertility rates.
• Betsy Booren of the American Meat Institute: If people try to consume the same amount of protein from plant-based foods, people could end up consuming more calories than if they had simply eaten some lean meat or poultry.

And, the National Dairy Council and the International Dairy Foods Association approved of the recommendation for three daily servings of low-fat or fat-free milk or dairy foods, but asked that the final guidelines acknowledge that flavored low-fat milk [i.e. chocolate] can encourage consumption among children.

With the politics out of the way (see yesterday’s post), let’s talk about what’s superb in the Dietary Guidelines Advisory Committee Report: the scientific review and analysis.

This was based on reviews produced by the Nutrition Evidence Library (NEL), which apparently recruited dozens of people to identify articles, assess their quality by uniform criteria, and rank the overall evidence as limited, moderate, or strong and consistent or inconsistent.

I particularly like the way the report organizes the research review by questions (of which there are 56, if I counted right).  The questions cover a great range of topics.  Examples:

• What nutrients and dietary components are overconsumed by the general public?
• Can a daily multivitamin/mineral supplement prevent chronic disease?
• What is the role of prebiotics and probiotics in health?
• What are health effects related to consumption of nuts?
• What are the health effects related to consumption of chocolate?
• How do the health outcomes of a vegetarian diet compare to those of a diet which customarily includes animal products?
• How are non-caloric sweeteners related to energy intake and body weight?
• What amount of water is recommended for health?

Questions are followed immediately by Conclusions, Implications, and Review of the Evidence. All of this is written with great clarity, accompanied by thoughtful comments, and packed with useful information.

Here is just one example (I’ve emphasized the evaluative words):

What is the Relationship between Vegetable Protein and/or Soy Protein and Selected Health Outcomes? Few studies are available, and the limited body of evidence suggests that vegetable protein does not offer special protection against type 2 diabetes, coronary heart disease, and selected cancers. Moderate evidence from both cohort and cross-sectional studies show that intake of  vegetable protein is generally linked to lower blood pressure. Moderate evidence suggests soy protein may have small effects on total and low density lipoprotein cholesterol in adults with normal or elevated blood lipids, although results from systematic reviews are inconsistent. A moderate body of consistent evidence finds no unique benefit of soy protein on body weight. A limited and inconsistent body of evidence shows that soy protein does not provide any unique benefits in blood pressure control.

Readers may disagree with the committee’s research interpretations, but its conclusions deserve serious consideration.

And, if anyone wants to know the state of the available science on any of a large number of questions in nutrition, this report is the place to look first.

Student alert: I will be using this report in classes.

I’ve heard rumors that some members of the Dietary Guidelines Advisory Committee (DGAC) believe that commentators did not give a fair shake to their recently released report (see previous post).

I complained that the DGAC report is difficult to read because its pieces are presented online in a great many individual pdf files that must be downloaded separately.  Fortunately, Cornell student Daniel Green created a single Web-based file.

I have now read the report, or at least browsed through its 699 pages, and I agree that it is better than it first appeared and deserves a revisit (which I am doing in two parts, the second tomorrow).

As with previous Dietary Guidelines, both politics and science underlie this report.  The science components of this report are stunning—as good as such things get—and make this document an invaluable resource.

Why did everyone, including me, miss this?  Politics, of course.  The politics appear unchanged from previous versions (for that, see Food Politics).

The science in this report gives clear guidance for action.  But the report obfuscates its most important messages.

The Executive Summary makes the advice seem dull. The Summary is the part everyone reads first and often the only part anyone reads.  Try this:

The 2010 DGAC report concludes that good health and optimal functionality across the life span are achievable goals but require a lifestyle approach including a total diet that is energy balanced and nutrient dense…SoFAS (added sugars and solid fats) contribute approximately 35 percent of calories to the American diet….Reducing the intake of SoFAS can lead to a badly needed reduction in energy intake and inclusion of more healthful foods into the total diet.

Obesity, it says, is a big problem.  The food environment is a big problem.  What to do about them?  SoFAS.

The report introduces a new euphemism, SoFAS (Solid Fats and Added Sugars).  The meaning of added sugars is obvious.  But what are solid fats?  For that, you must wait until page 183 (on the Daniel Green file):

Solid fats are fats that are solid at room temperature. Solid fats come from many animal foods and can be made from vegetable oils through hydrogenation. Some common solid fats are butter, beef tallow (tallow, suet), chicken fat, pork fat (lard), stick margarine, and shortening. Foods high in solid fats include many cheeses, creams, ice cream, well-marbled cuts of meats, regular ground beef, bacon, sausages, poultry skin, and many baked goods (such as cookies, crackers, donuts, pastries, and croissants).

Earlier (p. 24), the report listed the principal food sources of SoFAS:

Solid fats (percent of solid fat intake)

• Grain-based desserts, including cakes, cookies, pies, doughnuts, and granola bars (10.9%)
• Regular cheese (7.7%)
• Sausage, franks, bacon, and ribs (7.1%)
• Pizza (5.9%)
• Fried white potatoes, including French fries and hash browns (5.5%)
• Dairy-based desserts, such as ice cream (5.1%)

Added sugars (percent of added sugars intake)

• Soda (36.6%)
• Grain-based desserts (11.7%)
• Fruit drinks (11.5%)
• Dairy-based desserts (6.4%)
• Candy (6.2%)

The report does not say to eat less of these foods; it talks about nutrients.  In various places in the report, the report says [with my comments in brackets]:

• Significantly reduce intake of foods containing added sugars and solid fats because these dietary components contribute excess calories and few, if any, nutrients. In addition, reduce sodium intake and lower intake of refined grains, especially refined grains that are coupled with added sugar, solid fat, and sodium. [Nutrients, not foods].
• Eat less of these: calories from SoFAS, added sugars, solid fats, refined grains, sodium, saturated fat. [Ditto]
• Significantly lower excessive calorie intake from added sugars, solid fats, and some refined grain products. [Ditto]
• Strategies to prevent childhood obesity should include efforts to reduce surplus energy intake, especially energy from foods and beverages that provide empty calories from added sugars and solid fats. [Ditto]
• Intake of caloric beverages, including SSB [sugar-sweetened beverages], sweetened coffee and tea, energy drinks, and other drinks high in calories and low in nutrients should be reduced in consumers needing to lower body weight.  [Only overweight people need to worry about these foods?]

Only once does the report say the clear and simple: “Avoid sugar-sweetened beverages” (p. 65).  Nowhere does it explicitly say to eat less steak, hamburger, French fries, pizza, cookies, or ice cream.

Like previous editions of the Dietary Guidelines, this one talks about foods in the context of eat more (fruits and vegetables).  For eat less advice, it switches to nutrients.  I’d call this obfuscation (and politics).

But the report—for the first time—emphasizes environmental influences on obesity:

The 2010 DGAC recognizes that the current food environment does not adequately facilitate the ability of Americans to follow the evidence-based recommendations outlined in the 2010 DGAC Report. Population growth, availability of fresh water, arable land constraints, climate change, current policies, and business practices are among some of the major challenges that need to be addressed in order to ensure that these recommendations can be implemented nationally.

What business practices?  It doesn’t say.  It does, however, recommend:

• Improve foods sold and served in schools, including school breakfast, lunch, and afterschool meals and competitive foods so that they meet the recommendations of the IOM report on school meals….
• Increase comprehensive health, nutrition, and physical education programs and curricula in US schools and preschools, including food preparation, food safety, cooking, and physical education classes and improved quality of recess….
• Remove sugar-sweetened beverages and high-calorie snacks from schools, recreation facilities, and other places where children gather.
• Develop and enforce responsible zoning policies for the location of fast food restaurants near schools and places where children play….

This is excellent advice.  But how about some suggestions about what individuals might do about it?

The report says little about food marketing.  Beyond “Develop and enforce effective policies regarding marketing of food and beverage products to children…,” the report says virtually nothing about the well documented impact of food marketing on children’s food choices, dietary intake, and health.  Unless I missed it someplace, the research review does not cite the Institute of Medicine’s 2006 landmark report, Food Marketing to Children and Youth: Threat or Opportunity.

It buries the need for policy changes in long wordy lists.  It states the needs for low-income Americans to have access to and afford healthier foods; to produce fruits, vegetables, and grains sustainably; to ensure household food security; to promote sustainable aquaculture; and to encourage the food service industry to serve healthier foods and smaller portions.  It does not—and perhaps cannot—recommend policy changes to achieve these important goals.

Overall, the report contains plenty of material for food, nutrition, and health advocates to work with, but you have to read between the lines to find it.

Recall the process.  This committee’s report is advisory. From 1980 through 2000,  dietary guidelines advisory committees actually wrote the final Dietary Guidelines.   No more.  Since 2005, the sponsoring agencies decide what the Dietary Guidelines will say.

The report is open for public comment until July 8.  If you think the Dietary Guidelines should provide clear, unambiguous advice about how people should eat to avoid obesity and how we can create a healthier food environment, now would be a good time to express your opinion.  Here’s how.

Tomorrow: The reason why this report is an invaluable resource—its science review.

Yesterday, I got a last-minute invitation to listen in on a USDA conference call announcing the release of the report of the joint USDA-DHHS Dietary Guidelines Advisory Committee (see www.dietaryguidelines.gov).

The call was remarkable for how little information it produced.  It was scheduled for half an hour, but started 12 minutes late.  Officials used most of the time to talk about how the committee was appointed, how the committee process worked, how transparent everything was, and how staff of USDA’s new Evidence-Based Nutrition Library (NEL) provided much of the research basis for the guidelines.  This left hardly any time for asking questions, and only five got asked.

From what I heard, the committee report says pretty much what previous accounts said it would (see my post on this).  If my notes on the call are correct, the committee report will recommend:

• Maintain appropriate body weight through diet and physical activity
• Shift to a more plant-based diet
• Eat more seafood; eat more low-fat dairy products; limit meat intake
• Eat less solid fats; eat less of added sugars
• Reduce sodium; eat fewer refined grains
• Follow physical activity guidelines

Is this news?  Isn’t this always what the dietary guidelines say?  Here, just for fun, are the first set of guidelines that came out in 1980.

The main difference seems to be the way the evidence was judged and in some of the details: the target for saturated fat is 7% and for sodium a gradual reduction to 1500 mg/day.

If so, that’s a lot of trouble to go through to get to basically the same place.  I summarized that place in What to Eat as “Eat less, move more, eat plenty of fruits and vegetables, and don’t eat too much junk food.”  Michael Pollen did it even more succinctly: “Eat food.  Mostly plants.  Not too much.”

So why would two federal agencies and 13 committee members go to all this trouble?

The quick answer is that the agencies have to.  Congress says they have to review the guidelines every five years.

The longer answer, which I discuss in Food Politics and What to Eat, is that every word of the dietary guidelines is fraught with politics.

According to Food Chemical News (June 14),

The document is frequently the source of much controversy in the food industry because of the way it is used to promote certain ingredients and eating habits…Observers expect some controversy this year over recommendations made with regard to salt, a subject discussed frequently in committee meetings, as well a possible suggestion to replace two servings of grain with two servings of vegetables.

Another controversy is brewing in regards to the information on which the report was based. On Friday, the American Meat Institute, the National Cattleman’s Beef Association, the Grocery Manufacturer’s Association and the Grain Foods Foundation were among 23 groups that asked USDA and HHS to provide access to the Nutrition Evidence Library, which contains all the research used by the Dietary Guidelines committee when making their recommendations. “Without access to the data from which the DGAC drew its conclusions and recommendations, the public may not be able to provide meaningful comments,” the letter states.

Right. And now let’s see what the agencies do with this report (here’s the USDA press release on what happens next and how to comment).  This report is, after all, merely advisory. Now, the real politics begins!

Additions:

Here is all the information about the Advisory Committee’s report, and the report itself (but why didn’t they put it in one easy pdf file?).

And here is USA Today’s take on it: “Panel: obesity is century’s greatest public health threat.”

Further addition, June 16: Thanks to Daniel Green (Cornell) for putting the report together in one enormous (19MB) file.

By congressional fiat, federal agencies must revise the Dietary Guidelines every five years. This is one of those years.   The 2010 Dietary Guidelines Advisory Committee has been meeting for a couple of years and is now nearly done.

Some unnamed person from the American Society of Nutrition must be attending meetings.  The society’s Health and Nutrition Policy Newsletter (April 22) provides a report.

From the sound of it, this committee is doing some tough thinking about how to deal with “overarching issues” that affect dietary advice:

• The high prevalence of overweight and obesity among all Americans
• The need to focus recommendations on added sugar, fats, refined carbohydrates, and sodium (rather than the obscure concept of “discretionary calories” used in the 2005 guidelines)
• The benefits of shifting to plant-based, rather than meat-based, diets
• The need to help individuals achieve physical activity guidelines
• The need to change the food environment to help individuals meet the Dietary Guidelines

Applause, please, for this last one.  It recognizes that individuals can’t do it alone.

The committee’s key findings and recommendations:

• Vegetable protein and soy protein: little evidence for unique health benefits, but there are benefits, such as added dietary fiber intake, from diets high in vegetable and soy proteins.
• Carbohydrates: a consistent relationship between soft drink intake and weight gain. Overweight and obese children should reduce overall energy intake, especially from added sugars (and especially in the form of soft drinks and sugar-sweetened beverages).
• Fats: mono and polyunsaturated fats, when replacing saturated fats, decrease the risks of heart disease and Type 2 diabetes in healthy adults. No benefit from increased intakes of omega-3 fatty acids above 250-300 mg a day.  Adults should eat two servings of fish per week to obtain omega 3 fatty acids.
• Sodium: decrease sodium intake to 2,300 mg sodium per 2,000 calorie diet to lower blood pressure in adults and children. Since 70 percent of the population is hypertensive, the goal for most individuals should be 1,500 mg per 2,000 calorie diet.
• Potassium: because higher intakes of potassium are associated with lower blood pressure, adults should increase intake to 4,700 mg daily.

Translation: more fruits and vegetables, fewer processed foods, and changes in the food environment to make it easier for everyone to follow this advice.

Next steps: the committee is supposed to complete its report by May 12 and send it to USDA and DHHS. The agencies post the report in June for public comment. Then, agency staff write the guidelines and publish them by the end of the year.

Historical note: prior to 2005, the committee wrote the guidelines.  I was on the 1995 committee and we drafted guidelines that the agencies hardly touched (except to tinker with the alcohol guideline, as I discussed in Food Politics and What to Eat).  The guidelines have always been subject to political pressures, but with the agencies writing them, expect even more.

Let’s hope the committee’s sensible ideas will survive the process.  I will be paying close attention to how the 2010 guidelines progress.  Stay tuned.

I recently received this request from Daniel posted to Feedback:

Would you mind writing a blog post on the new surgeon general’s obesity report? …Is there a food politic element to why this has gone under the radar? …I find it ironic that Michael Pollan’s Food Rules generated substantially more press than a report by the United States Surgeon General.

I’m not surprised.  Pollan’s book is a hot best seller (it’s #1 on Amazon books, and for good reason, in my opinion).   The need to prevent obesity and how to do it is not exactly front-page news.  And the new Surgeon General, Dr. Regina Benjamin, is still relatively unknown as a political force.

But let’s give Dr. Benjamin credit for taking on obesity in one of her first public actions: the release of “Vision for a Healthy and Fit Nation.”   The Vision, which comes with a press release and a fact sheet, recommends these actions to prevent obesity:

1. Reduce consumption of sodas and juices with added sugars.
2. Reduce consumption of energy dense foods that primarily contain added sugars or solid fats.
3. Eat more fruits, vegetables, whole grains, and lean proteins.
4. Control your portions.
5. Drink more water.
6. Choose low-fat or non-fat dairy products.
7. Limit television viewing time and consider keeping televisions out of children’s rooms.
8. Become more physically active throughout the day.
9. Breastfeed exclusively to 6 months.

These are all useful suggestions but we have heard them before.  The real issue is how to achieve them.  Here, the report disappoints.

The first two items should have grabbed attention: targeting soda reduction as as the first line of defense against obesity, and eating less junk food (my translation) as the second.

But Dr. Benjamin assigns parents the responsibility for feeding kids healthfully.  Fine, but what about about public health approaches to reducing soda consumption?  To pick a non-random example, soda  taxes are under intense debate right now.  Does Dr. Benjamin weigh in on such approaches?  Alas, no.  Only on the second-to-last page does she summarize suggestions from the Centers for Disease Control and Promotion (CDC), among them:

• Increase availability of healthy, affordable food and beverage choices in public service venues.
• Improve geographic availability of supermarkets in underserved areas.
• Improve access to fresh fruits and vegetables by providing incentives for the production, distribution, and procurement of foods from local farms.
• Limit advertisements of less-healthy foods and beverages.

I wish the report had focused on such ideas, instead of leaving them to an afterthought and personal responsibility. It’s great that the nation’s doctor cares about obesity but her Vision isn’t nearly as tough or realistic as it needs to be.  For that, we need the CDC or the report on food marketing to kids that the Institute of Medicine produced in 2005.

In 2001, Surgeon General David Satcher released the first government report on preventing obesity.  It got press. If this one didn’t, it could well be because it doesn’t break enough new ground.  Surely, it’s high time we got beyond blaming parents and instead started focusing on the need to create a food environment that makes it easier for parents and everyone else to make better food choices and be more active.

I hear that Michelle Obama will soon announce (tomorrow?) a new program to address childhood obesity.  I’m hoping that her program will take on some of the factors in the food environment that make it so difficult for everyone to eat healthfully.