Tuesday, November 20, 2007

You Can't Please Everyone

So not only did the Ontario Society of Nutrition Professionals in Public Health try to sandbag my presentation without my knowledge by not copying me on their letter of concern or contacting me to discuss the presentation, they also sent a representative to chastise me during the question and answer period.

In what seemed like a mini-lecture of her own, Ms. Mary-Jo Makarchuk who was clearly visibly angered with my presentation, had a bunch to say. In a nutshell:

  1. She wanted to assert that on the Food Guide advisory panel she sat on (the Dietary Reference Intake panel) there was no industry influence.
  2. She wanted to assert the importance of DRI values in the creation of the Food Guide and cited herself the WHO Report Diet, Nutrition and the Prevention of Chronic Diseases as important evidence therein.
  3. She wanted to chastise me for recommending Dr. Walter Willett's Healthy Eating Pyramid for two reasons - firstly because it includes oils which include calories in what she called the base of the pyramid and secondly because he recommends the consumption of alcohol in moderation if appropriate.
I called it a mini-lecture because she did not in fact ask any questions and the session's moderator at one point rightly asked her if she in fact had a question to ask at roughly which point Ms. Makarchuk sat down.

So let's go through her positions one by one, starting with the position that there was no industry influence in her committee.

True to a degree, but certainly not entirely true. While there was no one on Ms. Makarchuk's committee, the Expert Advisory Committee on Dietary Reference Intakes (DRI), whose income was derived solely from industry, there were certainly individuals on food industry payrolls and therefore people with clear conflicts of interest.

Now before I get into the specifics here let me be very clear, just because someone's on an industry payroll does not necessitate that they will be influenced therein against their clinical judgment. That being said, there's no doubt that being on an industry payroll should serve as a conflict of interest to serve on a committee whose recommendations would affect the industry in question. So on that 11 member Food Guide DRI Committee 3 had clear industry based conflicts of interest.

  • One had served as an adviser to the sugar industry, sits on the medical advisory board of the International Dairy Foods Association, and though not true at the time of the Food Guide's revision process, currently sits on the board of trustees of the CCFN an organization born out of the merger of the National Institute of Nutrition (a group representing over 180 food manufacturers) and the Canadian Food Information Council (an industry organization the the CSPI once referred to as, "a wolf in sheep's clothing").

  • Another committee member, sits on the scientific advisory panel of the Canadian Sugar Institute and is also on the Board of Trustees at CCFN and in 2005 she went on record with the CBC as stating, "research shows that even when 25 per cent of calories come from sugar, it's not bad for your health".

  • Yet another member, is the former director of the McGill University School of Dietetics and Human Nutrition who during her tenure on both the Food Guide DRI committee and at McGill secured ongoing funding from Fleishmann's yeast for her department. In fact, Fleishmann's includes McGill's logo on their Breadworld website. Perhaps not surprisingly, the Fleishmnann's site's healthy related links still refer to the 1992 Food Guide which of course recommended far more bread. It also specifically calls "whole wheat" a whole grain which as we know, in Canada is not in fact the case given that the Health Canada endorsed definition of whole wheat includes wheat where 70% of the germ has been removed.

  • For those of you counting, that's nearly 30% of her committee having food industry conflicts.

    Regarding DRIs, here I was really confused. I was confused because Ms. Makarchuk made specific reference to the World Health Organization's 2003 report Diet, Nutrition and the Prevention of Chronic Disease in reference to why a nutrient focus was important in the Food Guide's development. The thing is, and as I pointed out at the conference, that same report had this to say about focusing on nutrients,
    "Seldom is there a single "best value" for such a goal. Instead, consistent with the concept of a safe range of population averages that would be consistent with the maintenance of health .... Sometimes there is no lower limit, this implies that there is no evidence that the nutrient is required in the diet and hence low intake should not give rise to concern."
    On the other hand, with regards to whole foods, Technical Report #916 has a lot to say, as does reams of research into the effects of foods and their role in chronic disease prevention. The report states that foods protective against chronic disease include (in no particular order) fruits, vegetables, whole grain cereals, non-starch polysaccharides (from whole grains, fruits and vegetables), legumes, fish, fish oils, unsalted nuts (in moderation); water(as an indicator of energy density); while the foods causative of chronic disease include free sugars, preserved and red meat, salt preserved foods; salt (as distinct from sodium), hydrogenated oils, Chinese-style salted fish.

    Regarding Dr. Willett's pyramid let's start with the oils. It's true that Dr. Willett's pyramid includes plant oils near to the base of the pyramid, however Ms. Makarchuk's statement that oils make up the base is patently false. The base of Dr. Willett's pyramid is actually, "Daily Exercise and Weight Control" which of course involves control of calories. It's also crucial to point out here that the evidence on fats would suggest that far more important than a blind 90s style reduction in total dietary fat would be the substitution of healthy fats - fats like the plant oils, in place of trans and saturated fats.

    Regarding Dr. Willett's inclusion of alcohol, the statement on his Healthy Eating Pyramid is, "Alcohol in moderation if appropriate". If Ms. Makarchuk were to read Dr. Willett's work she'd learn that, "in moderation if appropriate" means,
    "For men, a good balance point is 1 to 2 drinks a day; in general, however, the risks of drinking, even in moderation, exceed benefits until middle age. For women, it's at most one drink a day"
    But that said since his pyramid came out there has been further work on breast cancer and alcohol that suggests the link therein is even stronger than we once thought. Consequently yesterday I emailed Dr. Willett as to whether or not this new evidence would change his recommendation and here is his reply,
    "As you say, the issue of moderate alcohol consumption is complicated, especially for women because there is a small increase in risk of breast cancer with even one drink per day. However, there is a substantially larger decrease in risk of heart disease for the same amount of alcohol, so total mortality is reduced (and as you say, this applies to middle aged women and older). Further, there is quite a bit of evidence that if folic acid intake is adequate (getting the RDA), there is little or no increase in risk of breast cancer, so the balance of risks and benefits becomes even more favorable. For these reasons I don't plan to modify the pyramid at this time."
    Hearing the clear anger in Ms. Makarchuk's voice when she was talking at me really confuses me. Aren't we supposed to be on the same side? Does she actually recommend that her public health messages (she's works for the Public Health Division of the Ontario Ministry of Health) include the consumption of red meat, refined grains and willful caloric ignorance? I quite doubt it.

    I also don't understand why so many folks take this so personally, like the person who cornered me after the conference who was quite literally sputteringly angry at me for my utilization of evidence from two of the longest standing and largest epidemiologic nutritional studies (the Nurses Health Study and the Health Professional's Follow up Study). Not sure what she'd have preferred but in my talking with her she also readily admitted that she herself recommends patients minimize red meat and refined carbohydrates - once again the very messages I was suggesting should have been included in Canada's Food Guide.

    So to sum up my confusion, what I really can't understand is how, if you are a person who is passionate enough about nutrition for it to stir in you emotions like anger, how you can stare at our nutritionally indefensible Food Guide and then yell at me?