Saturday, November 18, 2006

Health Canada Quobesities

While researching this series, I read through a great many comments made by Health Canada officials regarding the Food Guide.

Some were remarkable due to their comparison with the path the Food Guide revisions have actually taken, and others were remarkable simply due to what was said.

In no particular order, what follows are some of my favourite Health Canada Food Guide related Quobesities:

1. On obesity in general

"Obesity is a very complex issue but I think that we’re not needing to label it as a disease"
despite it being labeled a disease by the World Health Organization , the National Institutes of Health, and virtually every major medical organization in the world.

2. On blindly following the Food Guide to maintain a "healthy weight" without paying any attention to calories,
"Canadians who follow the draft guide will in fact find that they will maintain a healthy weight"
Magically I suppose.

3. On the revision process,
"The revision process is evidence-based, collaborative, transparent and tied to public-health priorities",
but don't ask them to show you the revisions, the evidence or the process itself because those are secret.

4. On what the industry actually contributes to the Food Guide revision process,
"The lobbying is intense but the revisions will be based on proper nutrition."
And in the same article a note saying that the Beef Information Centre is pushing for more beef (got it), Refreshments Canada is pushing to not have a list of good and bad foods (got it), Kellogg's is lobbying over serving size (got it), and the Canadian Poultry and Egg Processors Council pushing to ensure that the Food Guide doesn't specifically call out packaged and restaurant foods (got it).

5. On fruits and vegetables,
"For example, we know that fruits and vegetables provide protection against forms of cancer and cardiovascular disease"
BUT they're going to recommend that you eat less of them!

6. On "Other" foods,
"It means we're talking about breads and cereals, not croissants and muffins. There's very little room for extras in this pattern such as cakes pastries, french fries, ice cream and alcohol. It requires different choices to be made"
BUT they won't provide you with any guidance on other foods, they'll simply pretend they don't exist despite the fact that they know that Canadians on average get 25% of their calories from "Other" foods.

7. On their revision,
"What we did in November was come out with a platform. It was the best we could do at the time. What we heard back was, "Sorry, it's not good enough". So what we've done is take the nature of "Sorry, it's not good enough," and we have taken the next steps."
22 months was just not enough time to come out with a good product? What? You want to see the changes they've made? Sorry, not going to happen.

8. On those very changes,
"Help me guys, is there another piece here?"
Question asked by Health Canada official to other Health Canada officials after Liberal MP Ruby Dhalla asked if they could provide another example of the changes they'd made to their "Sorry, not good enough" draft after they had provided the singular example of sodium.

9. On their listening skills,
"So we've spent an enormous amount of time trying to take the input that's been given to us, understand it, reflect on it, and make sure that when we finish the process we have something that's stronger"
Yet when they asked Dr. Arya Sharma, the head of the Canadian Obesity Network if he felt there should be guidance on Calories and he said to them "YES", their enormous amount of time taking his input, understanding his input and reflecting on his input led them to report to the House of Commons that,
"I can tell you that we've actually met with the scientific director of the Canadian Obesity Network, Dr. Sharma. We asked him whether he thought we should be talking about caloires. His answer was no."
10. On nutrients being more important than foods,
"An earlier comment said that we seem to be preoccupied with nutrient adequacy. We are not. If I leave you with one thought, it is that the chronic disease prevention components of this guide are every bit as important to us as the nutrient adequacy"
Yet they do not recommend maximizing whole grains and minimizing refined, they do not recommend decreased red meat consumption, they do not recommend the preferential consumption of fish over other protein sources, they recommend you eat fewer fruits and vegetables and plenty of dairy despite the fact that ALL of those shortcomings fly in the face of what we understand about diet and the prevention of chronic diseases.

11. On using current Canadian dietary habits as a design basis,
"We can't develop a de novo pattern"
Ummmmm, why not?

12. On the release of the new Food Guide,
"I can categorically tell you that when this Food Guide comes out there will be criticism"
Well isn't that something, I actually agree with Health Canada!

What Can You Do? - Some ideas about how to make your concerns known, and where can you turn to for sound dietary advice?

Yesterday: Guidance? What Guidance? - The sage advice of the Food Guide on how to manage your weight

What Can You Do?

Well if you haven't guessed it already, my first piece of advice is, don't follow Canada's Food Guide. It's not even remotely reflective of our current understanding of the effects of food on chronic disease prevention, it's rife with the involvement of politics and the food industry and if you do choose to follow it, you'll probably gain weight.

Does the fact that Health Canada is about to release this Food Guide without allowing for any further input or revisions upset you? Does it bother you that it's what's going to be taught to your children in schools, handed out in doctors' offices and taught as gospel to dietitians across Canada? Do you find it frustrating that those Canadians who are concerned enough to look for help with either nutrition or weight management will be pointed towards a terrifically flawed food plan?

If it does, then consider actually doing something about it.

Noise actually does make a difference and one of the best ways to make noise is to write or better yet call your local MP and explain to them your concerns. If you're not sure who your MP is, no worries, simply click here and using your postal code, you will be provided with your local MPs name, telephone number, fax number and email.

If you'd like, cut and paste the following brief message, modify it as you see fit and email away,

Dear (insert your MP's name here),

I am writing to you today to voice my concern regarding the pending release of the revised Canada's Food Guide to Healthy Eating. The recommendations being made by the draft guide are not reflective of science and medicine's current understanding of the impact of diet on chronic disease prevention, including but not limited to obesity.

Considering the fact that at least 25,000 Canadians die annually due to diet and weight related illnesses at a cost to Canada of over $6 billion dollars, to ignore this issue would be a grave mistake.

It has been 14 years since the Food Guide's last revision. Expert physicians and representatives from the non-profit nutritional advocacy group the Centre for Science in the Public Interest have testified before the House of Commons Standing Committee on Health as to the dietary shortcomings of this pending release.

I am writing to you today to urge you to ensure that before a new Food Guide is released and before we are subjected to another 14 years of inaccurate dietary advice and consequently unnecessary morbidity and mortality for Canadians, that both the draft Food Guide and the process by which its recommendations are crafted be reviewed.

Another way to make noise is to spread this series around. The link to the kick off of this series is here:

Please link to it on your websites, blogs, any forums you might frequent and in emails to your friends and families lists. The more people who are aware of how Health Canada has handled these Food Guide revisions, the more likely that meaningful improvements take place.

In terms of an evidence-based plan for healthy eating, look no further than the picture at the top of this post. That's a picture of Dr. Walter Willett's Healthy Eating Pyramid. Not only is it evidence based, but part of that evidence was Dr. Willett's proof that following it demonstrated a markedly reduced risk of chronic diseases vs. following the American (and for all intents and purposes the Canadian) Food Guide. For a detailed trip through his recommendations, pick up his fabulous book, Eat, Drink and be Healthy

With regards to weight management, you have to separate the concept of healthy eating from weight management. Healthy eating wise, stick to Dr. Willett's pyramid. Weight management wise, lessons learned from the National Weight Control Registry along with my experiences with close to 1,000 patients suggest the following Top Ten style list to be extremely important for successful weight management:
  1. Figure out how many you burn in a daytime. The best calculator I've found to do this is located here. Eating 500 fewer Calories per day should lead to a weekly 1lb weight loss.
  2. Keep track of what you're eating - whether via a food diary, routine eating or your own system, knowing how many Calories you've had is extremely helpful in guiding your decisions. There are online resources to do so including Calorie King ($30/yr) and Spark People (free).
  3. Don't lose too quickly. Remember, if you don't like the way that you're losing weight, you're almost certainly going to gain it back when you stop living that way. The only way to lose weight rapidly is to eat far too little, and unless you plan on eating far too little forever, it's not a good plan.
  4. Don't get hungry! Eat 3 meals and 3 snacks daily, not going more than 3 hours without eating. Waiting until you're hungry to eat will of course lead to more challenges - we don't crave green leafy salads when we're hungry
  5. Try to include protein with each meal and snack as protein is more filling, delays the body's absorption of carbohydrates and helps smooth out the body's insulin response.
  6. Practice Calorie awareness! Before I buy anything I look at the price tag. Before I eat anything, I check out the Calories. Doesn't mean I don't eat high Calorie items from time to time, it's just that I pick and choose when. Not knowing the Calories before I ate would be like me shopping by handing out blank checks.
  7. Eat breakfast! Make sure that you have at least 300 Calories, that it's within at most an hour of waking and that protein's included.
  8. Minimize eating out. If you're not in charge of the cooking, you're not in charge of the Calories and Calories sell. A restaurant's job is to bring you back. Their portions will be larger and their ingredients higher in Calories. It's extremely challenging to lose weight with frequent meals out.
  9. Don't drink your Calories. Liquid Calories don't help with feeling full. Fruit juice drop per drop has more Calories than Coca Cola. Milk as discussed in a prior post, may not be the healthiest drink in the world. I recommend lots of water and taking advantage of the myriad of zero-calorie beverages available. While much to do has been made about potential risks of sweeteners, every rigorous scientific study has found them to be safe, however even if you want to worry about the potential for a remote or rare risk, there's no doubt there are greater risks with weight.
  10. Find as many ten minutes as possible to exercise (brisk walking, housework, playing with your kids all count). Exercise for weight management is cumulative - it's like going to the bank. If you deposit $10 four times a day at the end of the day you've got $40, you don't need 40 minute blocks of exercise to make a difference. Aim if you can for between 250-350 minutes of exercise weekly. A great book on the subject is the No Sweat Exercise Plan by Harvard cardiologist Dr. Harvey Simon
Not included in the Top Ten list but perhaps more important than anything is the following: Don't set number goals. There are lots of numbers that you might try to pick on or goal set with - weight, body mass index, body fat percentage, waist circumference, waist-to-hip ratio. Frankly they're not that useful. They're really only useful for two things. Firstly you can use them to try to work out whether or not your weight carries with it any medical risk and secondly you can use them as potential calls to action, but I've got to reiterate, don't set goals with them.

The only goal worth setting is living the best you can. If you can't eat less and you can't exercise more within the context of a lifestyle that you're actually enjoying, then whatever your weight is, it's great. Remember that even a 5% weight loss has a significant medical benefit.

I hope you enjoyed this series on Canada's Food Guide and while I'm not holding my breath, maybe with enough noise you won't soon be reading an editorial written by me about how bad our new Guide is when it does officially get rolled out.

Yesterday: Health Canada's Quobesities - My favourite quotes from Health Canada officials on the matter of the Food Guide.

Guidance? What Guidance?

Obesity and overweight rates in Canada are skyrocketing. Official statistics state that almost two thirds of our population is overweight or obese. Fact is, the number actually probably closer to three quarters. If you click on the picture above you'll see obesity rates (overweight not included in slide) based off of measured Canadian heights and weights whereas all the official statistics are based off of self-reported heights and weights - turns out when Health Canada calls to ask how tall and heavy we are, many Canadians under report their weight and/or over report their height.

So if 65-75% of the population is overweight or obese, and if obesity costs Canada close to $7 billion per year in direct health care and lost productivity costs, and if obesity is responsible for the death of 1 in 10 Canadians between the ages of 20 and 64, and if at one of obesity's root causes are the foods we're choosing, and if the Food Guide revision was launched with obesity as a primary focus, and if we ignore the fact that the calorie models are flawed and that by focusing on nutrients we ignore the bigger picture of chronic disease prevention (including but not limited to obesity), then what sage advice does this new Food Guide provide Canadians on how to manage their weight?

For your benefit, I am going to copy every single statement from the Food Guide that relates to what they refer to as "Healthy Weight".

  1. Aim for the number of choices recommended in "Your Guide to Daily Food Choices" for your age and sex.
  2. Try not to eat too much more or too much less.
  3. Be aware of your portion sizes. Use the Food Guide to assess how much you eat.
  4. Choose foods and beverages that are lower in Calories and fat
  5. Be physically active each day
  6. Eating the amount of food suggested in "Your Guide to Daily Food Choices" should help adults achieve and maintain a healthy weight. You can tell if you are eating too much or too little food by how your weight changes over time.
  7. If you are at a healthy weight and find that you need more calories, have more choices from the four food groups.

So let me get this straight. Obesity's one of the main reasons Health Canada launched the revision process, contributes dramatically to our health care expenditures, kills tens of thousands of Canadians each year and the sum total of their advice is weigh yourself daily and if you gain weight eat less? Gee, that's helpful.

I especially like the point that explicitly tells Canadians that if they're at a healthy weight and need more calories, they should eat more! Doesn't eating more calories cause weight gain? Shouldn't there instead be guidance on how to utilize behaviour and food choices so as to minimize, if not eliminate hunger?

The problem is Health Canada seems mired in the ridiculous notion that "Healthy Eating" leads you to "Healthy Weights". Healthy eating and weight management are two completely separate entities. Healthy eating involves the foods that you choose, while weight management involves the Calories you choose. You can gain weight eating only salad if you eat enough of it.

Don't believe me? Here's a sample diet that our registered dietitian Shawna Hunt created and presented to Health Canada at our sit down meeting. She designed it using the draft Food Guide and adhered to its every rule and recommendation as applied to women between the ages of 18-50. It's meant to represent what a person might consume while trying to "Eat Healthy", but without understanding Calories. Eat it and you'll consume 2800 Calories of very healthy food. She even went light on the "Other" foods despite the fact that as you've read, they make up 25% of the energy you're consuming.

So if obesity's a great concern for Health Canada, and if "Energy" is measured in Calories, why isn't there some guidance surrounding Calories.

Do you think it would be useful to know roughly how many Calories your body burns in a daytime? If you knew how many Calories you burned, it would almost certainly influence your decisions as to what to eat. The easiest analogy is money. You need to know how much money you make in order to determine not only how much you can spend, but also to give you an understanding of the value of money because if you don't know how much money you make, knowing how much something costs becomes much less useful. Similarly, if you don't know how many Calories you burn, that big, bold first piece of information on the Nutrition Facts label, Calories, can't help you as much. It's less helpful because while of course you know that more Calories lead to heavier weights, if you don't know how many you burn, you won't know how much is too much.

If we take that hypothetical, sedentary, 5ft 4inch 50 year old woman, she would likely do well to know that at a healthy weight, she only burns on the order of 1500 Calories per day. Knowing that may make her think twice about whether or not she needs the 750 Calorie Starbucks Island Oat bar featured in a prior post.

Sadly, when discussing this very issue, Health Canada resorted to out and out lying. Here's the exchange from the October 24th meeting at the House of Commons. Health Canada had just been asked if they knew about my concerns regarding their lack of Caloric guidance,
"It is a perspective that I know has been expressed by him, and it is a perspective that isn't shared widely by others. We take this very seriously. We don't just casually say we don't agree with something. We are very careful about this.

I can take tell you that we've actually met with the scientific director of the Canadian Obesity Network, Dr. Sharma. We asked him whether he thought we should be talking about Calories. His answer was no."
Actually, his answer was "Yes".

Unbeknownst to Health Canada, Dr. Sharma and I had just spent the weekend at the Obesity Society conference in Boston and we found some time to chat. Among other discussions, we had talked about the value of Caloric guidance and the role of what I'll call Caloric awareness in helping our country's obesity concerns. I emailed him about what Health Canada had reported that he'd said and here's his response,
"Interesting, because I also just heard from Mary Bush.

I don't think I ever said Calories are not important and no guidance should be given ...

I think I did agree in general that there should be some guidance for normal Caloric intake - making it clear that there is a range compatible with maintaining a normal weight and that individuals' requirements may vary ...

I think, all I said was that I did not feel strongly about Calorie counting - but I agree that for people to have some idea of their requirements and some general idea about how many Calories are in what foods would be helpful."
So did Health Canada knowingly lie? Probably not. The slightly nicer than lying option, is that when Dr. Sharma clearly stated that he thought some basic Caloric guidance would be useful, Health Canada wasn't actually listening they were just hearing.

As I've been saying throughout this series, the issues I'm bringing up are not medical secrets. The fact that at the end of the day eating more calories than you burn leads to weight gain - is not a surprise or a secret to Health Canada, it's just that Health Canada clearly chooses what it wants to hear rather than relying on best evidence to guide their guidance.

Tomorrow: Health Canada's Quobesities - My favourite quotes from Health Canada officials on the matter of the Food Guide.

Yesterday: Oh, and you Can't have Ketchup - How Health Canada has ignored 25% of your dietary energy intake.

Oh, and you can't have Ketchup!

I sure hope you don't like ketchup.

I also hope you don't like jams, jellies, potato chips, chocolate, soft drinks or alcohol because as far as Health Canada's concerned, you simply can't have them. For they are the Other foods of the 1992 Food Guide, but in our new version, Health Canada would prefer to pretend that they simply don't exist.

Funny thing about them not existing.

I sure think they exist. I'm sure you think they exist. Statistics Canada sure thinks they exist. In fact Statistics Canada thinks that Canadians obtain almost 25% of their total daily calorie intake from these "Other" foods, a result none too surprising since identical results came from a 2001 study in the Canadian Journal of Dietetic Practice and Research.

Ok, so maybe I'm taking a bit of blogger license by stating that Health Canada doesn't think Other foods exist. Actually, I'm being kind, the truth is far more disturbing. Health Canada knows they exist, but they choose to ignore them.

Health Canada, during their questioning in front of the Standing Committee on Health had a few succinct words to say about their approach to "Other" foods,

"The issue is very dead-on. Canadians consume a large percentage of their energy--22% for ages 4 to 18, that we know from CCHS 2.2--from foods that aren't part of your basic food supply. I will repeat what I said earlier. This food guide is talking about tough choices."
They report that their Guide leaves little room for error, meaning that if you were to stray from the Guide even a little, you may well find yourself gaining weight.

Let's pretend for a moment (and I really mean pretend) that Health Canada's caloric modeling, despite it being based off out-dated and artificial 1997 Nutrient File calories is correct. If you take their calories and then add 25%, well that's a heck of a lot more calories!

Hey wait a second, doesn't consuming a heck of a lot more calories lead to weight gain?

So let me ask you, do you think it's a good idea to simply ignore 25% of the food that Canadians are currently consuming? I sure don't, but if we resign ourselves to the fact that there are a lot of "tough" choices to be made here, as Health Canada themselves stated at the House, I suppose that must mean that Health Canada has provided us with some rock solid guidance as to how to find and minimize these "Other" foods since it seems as if their solution for "Other" foods is for Canadians never to have them.

Think again.

It is ridiculous to suggest that Canadians cannot and should not choose condiments. It is ridiculous to assume that Canadians will stop eating dessert. It is unconscionable that the new Food Guide ignores 25% of all of the foods consumed by Canadians, preferring to turn a blind eye than to craft helpful recommendations as the "guidance" you'll read about tomorrow is as ridiculous as ignoring the fact that Canadians consume a great deal of "Other".

Tomorrow: Guidance? What Guidance? - The sage advice of the Food Guide on how to manage your weight

Yesterday: A Match NOT Made in Heaven - The 1997 Nutrient File and Canada's Food Guide working together to increase obesity.

A Match NOT Made in Heaven

Back in April my concerns regarding calories and the draft Food Guide were published in the Canadian Medical Association Journal (CMAJ). This wasn't the first time I had voiced my concerns, the first time was at a Think Tank on obesity where I had the opportunity to lunch with Health Canada officials. At that time my concerns were dismissed seemingly out of hand, but within days of publication in the CMAJ, Health Canada called and asked for a sit down.

As I mentioned in my earlier post, Consultation, What Consultation, to me at least it seemed that Health Canada certainly wanted to hear me, but did not especially want to actually listen to me. They spent most of the meeting trying to explain the fact that they had done caloric modeling and that their diet models had fewer calories than Shawna, our dietitian, had predicted.

Counting calories is actually a pretty easy thing to do - there's really not a lot of room for error. There are many online and print resources for tracking calories, and as it turns out, it was due to Shawna and Health Canada's choices of resources (and Health Canada's refusal to acknowledge "Other" foods - will get to that tomorrow) that led to their differences in numbers.

Shawna used real-world resources. She used actual products' Nutrition Facts labels and the 2006 version of the Calorie King Calorie, Fat and Carbohydrate Counter. Health Canada on the other hand used the almost a decade old 1997 Nutrient File.

So let me ask you a question. If you were counting calories, but your calorie database was out-of-date do you think you'd be counting accurately?

Here's another question, if your calorie database grossly underestimated the number of calories in foods, do you think that maybe, even if you were keeping track, you'd be eating more calories than you thought?

Well guess what, the 1997 Nutrient File is terribly out-of-date and does indeed grossly underestimate the number of calories in foods, and that's one of the reasons why Health Canada came up with much lower numbers than Shawna did when calculating the calories following the Food Guide would lead you to consume.

To explain what I mean, I'll use an example. Before my House of Commons testimony I went into my local supermarket and looked at their bread section. While the 1997 Nutrient File and consequently the Food Guide conclude that a slice of multi grain bread weighs 26g and contains 65 calories, that was true with only 1 of the 31 total loaves available for sale. Of the remaining loaves, over 2/3 weighed 60% more than expected by Canada’s Food Guide. Two of the most popular multi grain loaves, Dempster's Multigrain and Country Harvest 12 grain each had slices that weighed 45grams and contained 130 and 135 calories per slice respectively or DOUBLE what the 1997 Nutrient File says they should.

Remember, with regard to weight, its currency is calories. If for one year the only thing I did differently was eat one sandwich with Dempster's or Country Harvest bread in place of the non-existent 1997 Nutrient File bread, I might gain 13.5lbs more than Health Canada would predict. Why? Calories. Don't believe me, here's the calculation:

(260cals Dempster's - 130cals Nutrient file) = 130 cals per day more

130 cals per day x 365 days per year = 47,450 cals extra per year

47,450 extra cals per year / 3,500 cals per pound = 13.55lbs
And of course it's not just bread. The 1997 Nutrient Files says a commercial blueberry muffin has 197 calories. Tim Horton's says it has 340 calories. It's even off on fruits and vegetables because the average sizes have grown. I weighed a potato at home and it was 75% larger than the ones listed in the 1997 Nutrient File and to my eyes, it looked like a pretty average sized potato.

The thing that's the most remarkable is that even if you take Health Canada's calorie models as accurate, they still recommend far too many calories. Health Canada informed me that a 19-50 year old woman following the new Food Guide would consume 1,750 calories daily.

Using that number let's take a pretty typical hypothetical Canadian - a 50 year old, sedentary, 5ft 4 woman. According to the Mifflin St-Jeor equation, currently the best equation we've got to predict calorie requirements, if she were to eat 1,750 calories daily that would lead her to a weight of 188lbs and a medical diagnosis of obesity with a body mass index of 32 (if you want to calculate this yourself, I used an exercise coefficient of 1.2).

So does the Food Guide contribute to obesity rates in Canada?

If it's followed it sure does - it recommends far too many calories. Of course whether or not the Food Guide's followed is a tough question to answer since formal studies have not been done to determine the percentage of the population who try to tailor their diets to meet the Guide's recommendations.

That being said, below is a graph from Statistics Canada detailing the average number of calories consumed by Canadians. Notice what starts to happen in 1992 when the then new Food Guide came out.

So what did the 1992 Food Guide recommend? Well it recommended that we consume 25% more meat, 50% more milk products, 67% more fruit and vegetables, and much to the delight of grain farmers I'm sure, 112% more grain products than the 1982 Guide.

Health Canada at this point usually likes to try to make me look ridiculous by trying to state that I place the blame for Canadian obesity rates solely on Canada's Food Guide. So I'll be very clear here, I'm not putting all of the blame of Canada's rising obesity rates on the Food Guide - but to pretend that it has not or could not be a factor would be a gross oversight given the dramatic increase in per capita calorie consumption that began in 1992, the dramatic rise in obesity rates in Canada since 1992, the fact that according to Statistics Canada, obesity rates between 1978-1992 had remained steady and the fact that the Food Guide recommends a ridiculously large amount of food.

Even according to Health Canada themselves, the 1992 Food Guide provided incredible amounts of food,
"If you follow the Food Guide, you will get between 1800 and 3200 Calories each day."
Take that same 5 ft 4 sedentary 50 year old and give her 2500 calories a day and given enough time, she could end up over 300lbs.

And you should know, that 2500 calories does not include "Other" foods, which Health Canada in their seemingly infinite wisdom, have simply decided to ignore in the coming Food Guide.

Tomorrow: Oh, and you Can't have Ketchup - How Health Canada has ignored 25% of your dietary energy intake.

Yesterday: Drink Lots and Lots of Milk - Don't worry about all that research that suggests that in fact it might not be so good for you.

Drink Lots and Lots of Milk!

Dairy is big business in Canada.

Last year's Canadian farm receipts from dairy totaled $4.8 billion which means as an industry, it likely contributes $15-20 billion dollars to the Canadian economy which definitely means we can refer to them as Big Dairy.

As noted in a prior post, Big Dairy takes their marketing very seriously and there's no disputing the fact that they're very good at it. Certainly if you were to ask folks on the street if milk was good for you, I imagine they would almost certainly say "Yes", that is unless you happen upon the chair of Nutrition at Harvard, Dr. Walter Willett.

Dr. Willett, when asked to review the draft Canada's Food Guide, seemed quite taken aback by its dairy recommendations. Here are his thoughts (I've added hyperlinks to pertinent research):

"Like the US Guideline, the draft Canadian guidelines advocate large amounts of dairy products. There is really not a credible scientific basis for this. The usual justification is that this will reduce osteoporosis and fractures, but large prospective studies (Study #1, Study #2), consistently show no benefit of high dairy consumption on fracture incidence.

The high dairy intake would not be a major issue if it were clearly safe. However, the US Guidelines completely ignored a very substantial body of data showing increased risks of aggressive and fatal prostate cancer with high dairy consumption (review article). Also, many studies have found increased risks of ovarian cancer with high dairy consumption. Although the findings for ovarian cancer have not been entirely consistent, a recent meta-analysis of prospective studies found about a 25% increase in ovarian cancer with lactose intake equivalent to three glasses of milk per day (in fact two meta-analyses concluded risk with high dairy intake, you can find the other study here).

Thus, there is actually more evidence to suggest harm than benefit from high dairy consumption. The exact amount that might be consumed with little risk is still not clear, but suggestion of three or four servings per day seem excessive given what we do know."
Health Canada was questioned in the House of Commons on Dr. Willett's Dairy comments. Here's what Health Canada officials had to say,
"We actually had somebody go through to do a review this morning, based on those quick notes that came to us. I feel very confident that the pattern we're putting forward absolutely does not create a risk for either of those diseases."
Fastest researcher in the West!

Let me ask you, which would you rather trust, the quick notes of a researcher with a clear conflict on interest (Here the Health Canada researcher has a clear conflict of interest because he or she would not want to report Health Canada's recommendations as being wrong the day Health Canada was summoned to the House of Commons to defend themselves), or the word of the man who actually conducted the studies, the second most cited scientist in the history of clinical medicine, arguably the world's leading nutritional epidemiologist and a man who has no vested interest whatsoever in what Health Canada recommends?

So why does the Food Guide love dairy so much? It's a strange love affair given the medical evidence showing more evidence of risk than benefit. It's a strange love affair given that dairy contributes over one third of the total amount of saturated fat in our diets. It's also a strange love affair given that roughly 10% of the population is lactose intolerant.

Good thing for Big Dairy that to counter the wealth of evidence that suggests we're recommending too much dairy, they've got representatives on virtually every level of the Food Guide's decision making process including the Guide's 12 member advisory committee. Imagine what might have happened to the recommendations if they didn't!

Monday: A Match NOT Made in Heaven - The 1997 Nutrient File and Canada's Food Guide working together to increase obesity

Yesterday: Eat Less Fruit and Vegetables - Amazingly that's part of Health Canada's new recommendations

Eat Less Fruit and Vegetables

When considering this post I was tempted to simply leave it at one line,

"Health Canada has actually recommended that men and women over the age of 18 consume fewer fruits and vegetables",
because it's such a mind-bogglingly poor recommendation that it almost speaks for itself.

The 1992 Food Guide recommended the consumption of up to 10 servings of fruits and vegetables daily. The draft Food Guide has reduced that number. Men between the ages of 18-50 are now instructed to have 8-9 servings a day and women 7-8. Turn 50 and apparently now Health Canada wants both sexes to only have 7.

Amazingly, Health Canada has tried to explain their fruit and vegetable reduction on the basis of lower numbers of fruits and vegetables leading to decreased calorie consumption. Frankly, aside from the choices of potatoes, dried fruits and fruit juices, the vast majority of all fruits and vegetables have fewer than 50 calories per serving. Contrast that with the 200 or so calories per serving of cheese or 88 calories per 50 grams of lean beef and it makes you wonder about Health Canada's math.

Makes you wonder about their research as well considering that diets higher in fruits and vegetables have been shown to:

  • Decrease the chances of having a heart attack or stroke
  • Lower blood pressure
  • Help prevent constipation and diverticulitis
  • Prevent cataracts and macular degeneration
  • Decrease memory loss
  • Decrease total caloric intake and aid in weight control

  • Those all sound like good ideas to me.

    The only other comment regarding fruits and vegetables and the draft Food Guide is that no caution is provided regarding potatoes. As noted in the Broken from the Get Go post, 40% of Canada's current vegetable consumption comes from potatoes and half of that consumption is in the form of french fries or potato chips. Given the calories, saturated and trans fats associated with fried potatoes and the studies implicating high potato consumption with diabetes, specifically recommending that we consume fewer potatoes, or at the very least, fewer fried potatoes, would be an important recommendation. Of course, the draft Food Guide, doesn't make it.

    There is however an amazingly stupefying comment regarding Health Canada's approach to high-fat potato consumption in a document that Bill Jeffery, the National Coordinator of the Canadian arm of the Center for Science in the Public Interest obtained using an access to information request. The document is from the Office of Nutrition Policy and Promotion, Health Canada and is dated June 2006 Document A-1 and its title is, Reading results from Food Guide Pattern Modelling: Outputs of modelling - Food Expenditure Survey derived spreadsheets. Ready for it? Here's the quote,
    "Sometimes to achieve nutrient satisfaction at the lowest energy cost, amounts of modelling subgroups needed to be removed from the model....For instance, to reduce the amount of fat and energy in diets, the amount allocated to higher fat potatoes was reallocated to lower fat potato choices"
    In English what that means is that Health Canada indeed did note that half of our potato choices were high-fat fried choices, however instead of actually guiding us to making better potato choices, or better yet, guiding us to fewer potatoes, Health Canada did something that even I have a tough time comprehending and believing (and as you may gather, my confidence in Health Canada's Food Guide revisions is not high), they chose simply to ignore the fact that we eat french fries and instead simply pretended that we don't.

    That sound you just heard was my jaw hitting the floor.

    Next week I will explain the irony of Health Canada talking about calories at all, but I'll finish this post by saying that while I agree that Health Canada ought to made significant reductions in the amount of food they recommend, fruits and vegetables certainly are not the group they ought to be picking on.

    Tomorrow: Drink Lots and Lots of Milk - Don't worry about all that research that suggests that in fact it might not be so good for you.

    Yesterday: All Meat is Good, and Please Eat More of it - Beef farmers rejoice, Health Canada recommends Canadians eat more beef and still doesn't tell us fish is a healthier choice.

    All Meat is Good, and Please Eat More of it!

    According to the Ontario Cattleman's Association, the average Canadian consumes 51.6lbs of beef per year and Canadian beef production contributes over $20 billion to the Canadian economy annually. Well hold onto your lassos folks, if Health Canada has its way, 2007 may be a banner year!

    Why is that might you ask?

    Well, Health Canada has increased the recommended number of servings of meat and alternatives for all men over the age of 14, from 2-3 servings per day to 4 servings per day, and as far as they're concerned, all meat and meat alternatives are good choices.

    I'll get into Health Canada's explanation for this increase in a moment, but first let's cover the question, are in fact all meat and meat alternatives equally healthy?

    So what are we comparing? We're comparing beef, poultry, fish, seafood, soy, legumes and nuts.

    Off the top of your head, do you think it's just as healthy to choose beef over fish or nuts?

    I didn't think so.

    Strange that Health Canada apparently does despite ample evidence proving that red meat simply is not as healthy a choice as other meat alternatives.

    Red meat consumption has been shown to be linked with the development of breast cancer, diabetes, and colon cancer, and of course as discussed yesterday, the saturated fat in red meat is tightly linked with the development of heart disease.

    Contrast that with data from fish (also covered in yesterday's post). Remember, using the Nurses Health Study, Dr. Walter Willett and colleagues have calculated that replacing just 5 percent of total calories currently consumed from saturated fat (primary sources in our diets are red meat and dairy) with unsaturated fats (like those found in fish and nuts) would reduce the risk of heart attack or death by about 40 percent. There's also been research showing that substituting fish in the diet specifically for red meat reduces bad cholesterol and that the omega-3 fatty acids in fish lower levels of LDL or bad cholesterol, help to prevent the increase in triglycerides in high carbohydrate based diets, reduce the development of irregular heartbeats (a major cause of sudden cardiac death) and reduce the tendency for clots to form in our arteries.

    You should certainly contrast the negative outcomes of high red meat consumption with nuts as well, as several of the largest epidemiological studies of our time, the Adventist Study, the Iowa Women's Health Study and the Nurses' Health Study have shown a 30-50% lower risk of heart attacks or heart disease associated with eating nuts several times per week and that including nuts in our diet helps prevent type 2 diabetes.

    Remember too, in terms of reducing saturated fats, there are none in beans and soy and far less in poultry than in beef (especially if you remove the skin of the bird).

    Dr Willett, in his review of the draft Food Guide had this to say on Health Canada's Meat and Alternatives recommendations,

    "the draft Canadian Guidelines make little distinction between consumption of red meat, beans, fish, and poultry. Although they advocate lean meat, this is only a small fraction of the red meat in the food supply and the guidelines are silent about usual cuts of meat and processed meats, which are a huge part of the North American diet. Thus, the Guidelines seem unbalanced; the evidence would suggest that red meat and particularly processed meats should be limited, and that a combination of fish, poultry, nuts, beans and soy, and occasionally lean meat be the primary protein sources."
    So bottom line, does the draft Food Guide differentiate between meat and alternatives. Nope. Buried in the draft Guide is indeed a recommendation that we eat fish once a week and "add variety by choosing alternatives such as eggs, nuts, peanut butter, hummus, seeds and tofu", but on the main pictorial page the wording's different, the category's actually entitled "Meat & Alternatives" certainly highlighting the "Meat". The instructions provided are, "Include a variety of lean meat, poultry, fish, beans and other alternatives", meat again leading off what we're told to choose and then of course there's the picture of the big juicy T bone.

    I need to comment here on the T-Bone. It's quite a remarkable picture to represent meat considering the fact that T-bones are certainly NOT lean cuts of meat. It's a downright ridiculous picture when you look underneath it and see that Health Canada suggests a serving is 50grams because the average T-bone weighs roughly a pound and therefore would make up 11 Food Guide servings.

    I won't bother getting into the picture of the chicken drumstick with the skin left on.

    And what's with the increased number of servings? Health Canada explains it by pointing out that they've reduced the serving size and therefore the increased number of servings, by weight, actually ends up reflecting a smaller total amount. They say this despite the fact that there is no research that would suggest we're eating too little in the way of meat, and ample evidence that would suggest we're eating too much.They also say this despite their own research that shows most Canadians don't know what a serving is and generally relate the amount they put on their plates to be a serving. Put meat on your plate four times a day and there's four servings.

    So if Health Canada wants us to eat smaller servings, do they instruct us to weigh and measure our food? Nope. Instead they've instructed us to use half the size of our palms to measure out meat portions. Guess what, palms vary pretty dramatically in size. I'm a pretty average sized guy and when I estimated the weight of my palm in ground beef I ended up with twice as much meat as what Health Canada called a serving. When my wife tried this, and she has incredibly small hands, even her portion was 10% greater than what Health Canada was recommending. Also there's the fact that as far as I'm aware, butchers don't sell half-palm sized cuts of meat.

    At the end of the day, there's no doubt that the evidence would support recommending we minimize red meat consumption and increase fish and alternatives' consumption, though I suppose a $20 billion dollar Canadian beef industry would want us to think otherwise.

    Tomorrow: Eat Less Fruit and Vegetables - Amazingly that's part of Health Canada's new recommendations

    Yesterday: All Fat is Bad - Fat phobia still runs rampant at Health Canada.

    All Fat is Bad

    At least that's what Health Canada has consistently told us.

    Would you be surprised to learn that the type of fat in your diet is much more important than the amount of fat in your diet?

    My guess is probably not - there's been a tremendous amount of very well publicized research that has proven that blindly following a low-fat diet doesn't seem to help with any particular health outcomes and that diets richer in healthy fats are, well, healthier.

    You might however be surprised at how much the type of fat you choose in your diet affects your health.

    Let's start with the bad fats, the saturated fats and the trans fats - there's no disputing the fact they're not good for you.

    Starting with saturated fats, Dr. Ancel Keys back in 1956 with the Seven Countries Study (another very important epidemiological data base) was the first to show that countries with diets higher in saturated fats had higher levels of heart disease. In his studies however, the total amounts of fats in the diet were not linked with heart disease and the country with the highest amount of total fat, Crete, also had the lowest rate of heart disease. Perhaps this is why results of clinical trials looking at simple overall fat reduction are not terribly impressive.

    In January of this year, a series of 3 articles came out in the Journal of the American Medical Association detailing the results of the largest dietary fat trial ever conducted. The study they were detailing was the Women's Health Initiative Controlled Dietary Modification Trial where 48,835 women were randomly assigned to a low-fat diet (less than 20% of calories from fat) or to a comparison group and were followed for over 8 years. The papers reported that low-fat diets did not lower the risks of colon cancer, breast cancer or heart disease.

    On to trans-fats. Trans fats today constitute roughly 3-7 percent of the calories we consume from fat. Trans fats come from shortenings, fried foods and many commercially baked goods (goods that almost always also use refined flours).

    Trans fats have been shown to raise bad cholesterol, raise triglycerides, lower good cholesterol and make our blood stickier increasing the risk of blood clots. Trans fats have also been shown to increase the process of inflammation in our body which in turn has been implicated in heart disease and diabetes and may well also be involved in other disease processes.

    Using the Nurses Health Study again, Dr. Walter Willett and colleagues showed that women who ate the most trans fats (3% of total daily calories worth) were 50 percent more likely to develop heart disease over a 14 year period than those who ate the least. Conversely, women who ate the lowest amount of trans fats and the highest amount of healthy fats (we'll get to healthy fats in a moment), were 70 percent less likely to develop heart disease.

    The Center for Science in the public interest estimates that removing trans fat from the food supply in North America will prevent between 11,000 and 30,000 deaths per year and save over $50 billion dollars in annual health care expenditures. Interestingly Dr. Willett in his book Eat, Drink and Be Healthy states that he feels these numbers are underestimations as CSPI's report did not take into account the potentially harmful effects trans fats have on diabetes risk.

    In June 2006 Health Canada released the findings of their Trans Fat Task Force and made recommendations to our government for the elimination of trans fats from our food supply. Given the strength of the research as well as the degree of damage trans-fats cause, it's hard to fathom why our government is not acting on these recommendations.

    Now onto the good fats. The good fats are the unsaturated fats. Monounsaturated fats are found in vegetable oils, avocados and nuts and polyunsaturated fats are found in whole grains and fatty fish. You've probably read a great many claims about these fats and if your eyes have been open you've been seeing food products touting how much of them they contain, especially with regards to omega-3s. Omega-3 fats are unsaturated fats and there are three types of them, ALA, DHA and EPA. ALA is the most common, it's found in a variety of vegetable oils, while EPA and DHA come mainly from fish.

    Again using the Nurses Health Study and the Health Professionals Follow Up Study Dr. Walter Willett and colleagues have calculated that replacing just 5 percent of total calories currently consumed from saturated fat with unsaturated fat would reduce the risk of heart attack or death by about 40 percent. In contrast they also showed that replacing saturated fat with carbohydrates (like we're told to do by the Food Guide) showed much smaller reductions in risk.

    To summarize the studies on omega-3 fatty acids, they lower levels of LDL or bad cholesterol, they help to prevent the increase in triglycerides in high carbohydrate based diets, they reduce the development of irregular heartbeats (a major cause of sudden cardiac death) and they reduce the tendency for clots to form in our arteries.

    A famous study called the GISSI Prevention trial took more than 11,000 men and women who had survived a heart attack and randomly assigned them to taking either a placebo or a 1-gram capsule of omega-3s. At the end of 3 years, there were over 14 percent fewer deaths in the omega-3 group (sudden deaths cut by 50%) and fewer second heart attacks and strokes.

    So now that you've heard how terrible trans-fats are for you and how healthy unsaturated fats are for you would you like to know what the draft Food Guide had to say on the matter?

    Dr. Willett, on reviewing the draft Food Guide had this to say on the Guide's fat recommendations,

    "Like the US Guidelines, the draft Canadian document is still fat phobic. There is suggestion to use a very limited amount of vegetable oils, but there are recommendations to reduce or avoid fat in general, when it really trans fat in partially hydrogenated foods that should be totally avoided and saturated fat that should be limited. The main message should be to replace trans and saturated fat with unsaturated fats."
    The words trans fat do not appear even once in the draft Food Guide, this despite the ridiculously large amount of evidence pointing to the need for their elimination. Health Canada's own Trans-Fat Task Force report recommends we eliminate them from our diet and Health Canada's own labeling laws required trans-fat to be listed on our food labels. Why then don't they point us in the Food Guide to look for and steer clear of trans fats?

    Regarding healthy fats, the words unsaturated fats do appear twice. There's a statement that tells use to use vegetable oils high in unsaturated fats "most of the time", and then there's a statement to aim for a small amount of unsaturated oils or soft margarine each day. There's no mention of the healthy fats found in fish and the only call to action on fish is buried on page 6 where it says consume fish once a week. There's also no recommendation to try to replace some of the saturated fats in our diet with unsaturated fats (remember, replace 5% of one with the other and the risk of heart attack and death goes down by 40%).

    So just as with the data supporting the preferential consumption of whole grains over refined grains, the preferential consumption of unsaturated fat over saturated fat and the elimination of trans fats from our diets are as black and white as things get in medicine.

    Unfortunately our Food Guide seems hopelessly mired in gray.

    Tomorrow: All Meat is Good, and Please Eat More of it - Beef farmers rejoice, Health Canada recommends Canadians eat more beef and still doesn't tell us fish is a healthier choice.

    Yesterday: Please Eat White Bread - Why Wonder Bread's more in touch with the evidence on whole wheat than Health Canada.

    Please Eat White Bread

    Even Wonder Bread knows whole grains are healthier. They of course still have their original recipe, but now you can also choose 100% whole grain wonder bread and something they call whole grain white.

    The evidence on the benefits of whole grains are as impressive as the evidence on the risks of refined grains.

    Using the Nurses Health Study and the Health Professionals Follow-up Study, perhaps the two most important epidemiological studies in history, Dr. Walter Willett and his colleagues have shown that diets higher in whole grains reduce the risk of both diabetes and heart disease by 30% while also reducing the risk of stroke by 20%.

    A more recent study revealed that diets highest in whole grains carried with them HALF the risk of developing metabolic syndrome (a constellation of high blood pressure, insulin resistance and high cholesterol).

    Conversely, in those same studies, diets highest in white bread, white rice, french fries and cooked potatoes were all associated with increased risk of diabetes and in the study looking at metabolic syndrome, diets highest in refined carbohydrates carried with them DOUBLE the risk of its development.

    Why then does Health Canada want us to eat so much of the white stuff?

    The exact wording on the draft Guide states, "Make half your choices whole grain each day" which of course directly implies that the other half be refined.

    Dr. Walter Willett, in viewing the April 2006 draft Canada's Food Guide had this to say,

    "refined grains have little nutritional value and thus provide empty calories, reduce HDL cholesterol, raise triglycerides, are thus not surprisingly related to higher risks of type 2 diabetes and coronary heart disease. Refined grains should be on the list of foods to minimize, along with saturated fat."
    So again you might wonder, why exactly is Health Canada pushing the refined grains?

    Amazingly when trying to explain themselves to a reporter from the Citizen, Health Canada officials claimed that the reason they recommend half our grains come from refined carbohydrates was due to refined flour's mandatory fortification with folic acid and its affect on the incidence of neural tube defects.

    I spoke with Dr. Godfrey Oakley about this, he's one of the world's experts on folic acid fortification. There's no doubt that folic acid fortification of refined grains is one of the greatest public health triumphs of our time as mandatory fortification has silently reduced the risk of neural tube defects like spina bifida in our children.

    In recounting the history of folic acid fortification Dr. Oakley noted that Health Canada was very much opposed to fortification when it became mandatory in the United States in 1996 but due to pressure from the grain industry (who were already fortifying their products in the much larger market share of the United States) acquiesced and in 1998 made fortification mandatory in Canada as well.

    Despite this irony (certainly Health Canada is entitled to learn from their own mistakes), the argument is hollow and it really highlights the shortsightedness of worrying more about nutrients than about foods.

    While there's no doubt that reducing the incidence of neural tube defects is an important public health concern, I certainly wouldn't want to make the argument that it was more important than minimizing diabetes and heart disease.

    To put some numbers to this, since the introduction of mandatory folic acid fortification in refined flours, the incidence of open neural tube defects in Ontario has dropped from 1.13 per 1,000 pregnancies to 0.58 per 1,000 pregnancies.

    On the other hand, according to Health Canada, roughly 1 in 16 Canadians currently have diabetes, a number expected by the World Health Organization to reach 1 in 9 by the year 2025. Health Canada estimates diabetes currently costs Canadians close to $9 billion dollars a year.

    Heart disease according to Health Canada is,
    "the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national health care system."
    1 in 2 Canadians die due to heart disease.

    So what do you think are more important public health targets? Diabetes and heart disease or open neural tube defects?

    Does it make sense to you to recommend the consumption of refined carbohydrates to minimize the risk of open neural tube defects at the expense of increasing the rates of heart disease and diabetes? Would it not make sense to recommend diets higher in whole grains to decrease the risk of diabetes and heart disease and perhaps at the same time recommend a pennies-a-day multivitamin?

    Frankly, we shouldn't have to choose! There should be nothing stopping Health Canada from mounting a vocal and tireless campaign to fortify our whole grains with folic acid, allowing them then to recommend we minimize our consumption of diabetes and heart disease inducing refined flours and still consume enough folic acid to decrease our risk of open neural tube defects.

    The fact that Health Canada is not doing so again begs the question how much politics and the food industry influence their decisions.

    Tomorrow: All Fat is Bad - Fat phobia still runs rampant at Health Canada.

    Last Friday: Consultation? What Consultation - I suppose if by consultation you mean what fonts you like, then yes, there was an extensive consultative process

    Thursday, November 16, 2006

    Consultation? What Consultation?

    Health Canada is very proud of their consultative process. They will happily talk about their coast-to-coast consultations and how they spent more time doing outreach with this Food Guide revision than any other.

    With regards to their coast-to-coast consultations, it's true, they did travel coast-to-coast and they did indeed have an online consultation process open to all Canadians.

    Unfortunately, those consultations were about form, not substance.

    Don't believe me? Check them out yourself online where you can see that indeed Health Canada wanted input, it's just that the input that they wanted was pretty much relegated to what font you liked, what pictures you wanted, how many pages it should be, which vegetables should be pictured and so on.

    Still don't believe me? Here's a quote from Health Canada on the matter,

    "One of the criticisms is that there was little focus on the actual pattern and more focus on the packaging of the pattern. That was indeed a constraint that emerged out of the online approach to the consultation."
    Ok, so you might argue that maybe the online consultation should have been about form and not substance, after all they were reaching out to the average Canadian, not to folks with specialized knowledge in nutrition.

    Ok, well that leaves us with the in-person group consultations.

    Our registered dietitian Shawna Hunt attended the in person group consultation that took place in Ottawa on November 24th, 2005.

    She was excited to be given the opportunity to have discussions on what she saw were major shortcomings in the nutritional recommendations of the proposed Guide as well as the incredible number of calories it would lead Canadians to consume.

    Wanna know what she got instead?

    Pretty much the same forms involved in the online consultation.

    As far as discussions go, one of the more heated "discussions" that took place that day involved an industry representative from the Dairy Board who angrily argued that because the milk carton depicted in the proposed Guide's pictorial representation of food choices was slightly askew compared with the soy beverage, that those depictions might therefore lead Canadians to consume less milk and more soy. Important discussion for the Dairy board? Maybe. Important for the health and welfare of Canadians? Not so much.

    Ok, so the online consultation wasn't too impressive and neither was the group about the personal outreach?

    I experienced that outreach.

    Shortly after my views on the Food Guide were published in the Canadian Medical Association Journal, I received a phone call from Health Canada asking if we could set up a meeting. We of course obliged and within a week we met face-to-face with Health Canada officials.

    On the one hand, it was quite nice for them to have come to chat with us. Unfortunately, there was another hand. If the purpose of the meeting was for Health Canada to say that indeed I'd been "heard", then I suppose the meeting was a great success. The problem is, there is a very big difference between someone being heard and someone actually listening.

    Shawna, our dietitian, had prepared a number of test diets based off of the draft Food Guide's recommendations. She prepared a best case diet, a typical diet and a worst case diet to illustrate the incredible number of calories following the Food Guide would lead Canadians to consume.

    Among other objections, Health Canada objected to Shawna's choice of quinoa, a whole grain in one of her test diets, that her use of nuts was not an appropriate source of protein, and that avocados were not an appropriate fruit choice.

    We were both told that Health Canada had done their own modeling for calories and that their models were much lower than ours.

    I firmly and wholeheartedly believe that to be true.

    Frankly at the time, we couldn't understand (none of us, not I, not Shawna and not Health Canada) where the discrepancy in calories came from as it's not an especially difficult procedure to calculate calories and we and Health Canada were quite confident that we had done so correctly.

    In fact, we both had.

    The problem is, the reason their models are lower than ours is because, for a lack of a better term, the calorie-counting book they used is woefully outdated and it supplied them with non-real world data in the calculation of their calories (stay tuned for the post on this subject specifically).

    In the end I believe they left our offices, really not having heard much of what we had said, but concerned enough to apparently have told CTV that they refused to appear together with me in any type of debate style format (this is what CTV told me when I specifically asked them if they could arrange a frank and open discussion on air between me and Health Canada officials).

    Bottom line of course is the simple act of having consultations does not necessarily mean that the appropriate questions were asked during the consultative process, that the appropriate people were involved in the consultative process, and that if the appropriate people were involved that their input was included. Perhaps this is why on Halloween, included in their motion to have the draft Food Guide tabled before the House of Commons, the Standing Committee on Health members also asked that Health Canada table,
    "a list of people brought forward who were actually consulted, the types of questions that were asked, and also to ensure and take a look at where those suggestions ended up and whether or not they were incorporated into the food guide."
    At the end of the day, if Health Canada is so confident in their draft's revisions, why don't they simply release them for all to see?

    Nothing would please me more than to see that our concerns have been addressed and that in fact the Food Guide has undergone a dramatic overhaul and rejuvenation.

    Of course even if that were true, I would still be scratching my head about the process. The draft of the Guide that I've seen, that Dr. Willett has seen, that the Centre for Science in the Public Interest has seen, was released in April 2006, not in November 2005 as Health Canada purports. For those keeping track, April 2006 is 27 months after the revisions began. However even if we do talk about the November draft where as Health Canada officials themselves state,
    "What we did in November was come out with a platform. It was the best we could do at the time. What we heard back was, "Sorry, it's not good enough"
    I have to ask, why the heck wasn't it good enough? Was 27 months not long enough to come out with a Food Guide? Didn't they undertake an incredible number of consultations and conduct more outreach than any other Food Guide? What exactly did they do for 27 months? Were their experts lacking in expertise? Were there undue and irresponsible pressures being put to bear on those experts? Were their experts simply not listened to?

    After 27 months of research and work, I would expect something significantly better than, "Sorry, it's not good enough", after all, these aren't medical secrets we're discussing.

    Monday: Please Eat White Bread - Why Wonder Bread's more in touch with the evidence on whole wheat than Health Canada.

    Yesterday: At Least You'll Get Enough Zinc - Health Canada cares a lot about nutrients...not so much about foods. Last time I checked, I eat foods, not nutrients.

    Tuesday, November 14, 2006

    At Least You'll Get Enough Zinc

    Zinc is a micro nutrient, as are all vitamins and minerals that are essential in minute amounts for healthy cellular growth and metabolism.

    There's actually a micronutrient encyclopedia that details how much of them we need (called Dietary Reference Intakes or DRIs) printed by the Institute of Medicine (IOM). The IOM describes their work on DRIs as, "eight exhaustive volumes" (there's a great sales pitch) but if you'd like some lighter reading you can pick up their 560 page summary for the low-low price of just $44.96.

    As noted in yesterday's post, Canada's Food Guide has been explicitly modeled to ensure that Canadians who follow the Food Guide will meet their daily micro nutrient requirements.

    You might think that sounds like a good idea. Certainly having a vitamin or mineral deficiency can lead people to medical illness.

    I guess the question is what's more important, steering people to dietary choices that prevent micro nutrient deficiencies, or steering people to dietary choices that minimize the risk of chronic diseases?

    The answer's a no-brainer.

    The fact is there isn't a rash of micro nutrient deficiencies in Canada, and that's despite the fact that the majority of the population does not currently practice tremendously healthy eating. Even back in 1982 when the then Food Guide recommended the consumption of far less food (the 1982 Food Guide recommended that we consume 113% fewer grain products, 50% fewer milk products, 67% fewer vegetables and fruit and 25% fewer meat and meat alternatives) there were no micro nutrient deficiency outbreaks.

    The fact is, the bulk of our understanding of the role of diet on the prevention of chronic disease has to do with the effects of increased or decreased consumption of whole foods, not of micro nutrients.

    The fact is the burden of chronic disease in our society is climbing at an atrociously rapid rate (the WHO projects a doubling of cases of type 2 diabetes by 2025).

    The World Health Organization in their 160 page Technical Report Series #916, Diet, Nutrition and the Prevention of Chronic Diseases summarized the evidence for and against both nutrients and foods in the prevention of chronic disease.

    To quote the report with regards to targeting 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.

    To be consistent with our best evidence the WHO, and anyone who's up to date with the medical literature, would say that if our Food Guide reflected best available evidence it would be unambiguously encouraging Canadians to preferentialy consume (in no particular order):

  • Fruits
  • Vegetables
  • Whole grains
  • Legumes
  • Fish
  • Nuts

  • While minimizing the consumption of:

  • Free sugars (white rice, white flour, white sugar, potatoes)
  • Red meat, and more specifically processed red meat
  • Salt
  • Hydrogenated oils

  • I'm sure that the majority of you reading this blog already know the above lists to be true.

    Why then does the proposed Food Guide not make these explicit recommendations?

    Truly, I don't have the answer, but however you slice it, the answer is disturbing.

    Bottom line, in a country where there are no outbreaks of micro nutrient deficiencies; in a country with a tremendous burden of chronic complex diseases; with a Food Guide where the units of guidance are foods and not micro nutrients; with a backdrop of research where the wealth of our understanding lies again in foods and not nutrients; to have relied on micro nutrients to shape the recommendations rather than foods is at best short sighted and at worst, a dearly missed opportunity for change.

    Tomorrow: Consultation? What Consultation - I suppose if by consultation you mean what fonts you like, then yes, there was an extensive consultative process

    Yesterday: Broken from the Get Go - Get this, the new Food Guide is based off of current Canadian dietary patterns....where 40% of all vegetables consumed are potatoes with over half of the potatoes being consumed coming from french fries or potato chips. That seems smart.

    (To see the WHO summary on whole foods and chronic disease in more detail and a mirroring of the concerns of this post by the Centre for Science in the Public Interest (CSPI) please read CSPI's December 2004 formal submission to Health Canada on their then concerns on the revisions to the Canada Food Guide. Unfortunately since that time, their concerns haven't changed)

    Sunday, November 12, 2006

    Broken from the Get Go

    So let's say you've decided that Canadians aren't making the healthiest of dietary choices. Let's even say you're Diane Gorman the then Assistant Deputy Minister of the Health Products and Food Branch of Health Canada and you're kicking off the process of revising the Food Guide. You'll be quoted as saying,

    "The current edition of the Guide is 10 years old. Within this time, scientific knowledge about the relationship between diet and health has evolved. The lifestyle of Canadians has changed and the environment within which people are making choices about healthy eating has changed significantly."
    Suggesting of course that the Food Guide's going to have to help Canadians make healthier choices in our evolving and toxic food environment.

    Do you think that a good starting point for improving the choices Canadians make would be to collect data on what Canadians are currently consuming?

    I suppose it might be nice to have that information to contrast it with what you're going to be recommending.

    Do you think that using that information to ensure that you make as few changes as possible would be a good idea?

    Health Canada does.

    In an overly complicated document, Health Canada detailed their methodology on how they came up with the skeleton for our next food guide.

    To summarize as best I can,
    1. A pool of "food choices" was created using provincial food and nutrition telephone survey data from British Columbia, Manitoba, Ontario and Quebec.

    2. The popularity of what was most commonly being consumed in those provinces was given a rank. In a moment of clarity in the document Health Canada explains,
      "For instance, if the relative popularity of apples is 30% within the available fruit choices, then there is a 30% probability that apples will be included as any given fruit choice."
    3. 500 "Test" diets were created using the ranked popularity of foods for every age and sex group detailed by the proposed Food Guide.

    4. The test diets were evaluated to see if following them would lead Canadians to meet their nutrient requirements (a whole post will be devoted to why this isn't a great plan tomorrow). Here's Health Canada's quote on the matter,
      "The test diets are evaluated to see if nutrient requirements are met. The modeling switches back and forth until no further adjustments to the diet pattern are needed to achieve nutrient targets."
    5. Presto-NO-chango we've got new recommendations that stick as closely as possible to what Canadians are currently eating.
    It seems quite backwards to me that the basis for our new Food Guide should be our current pattern of eating.

    The Food Guide should be steering Canadians to healthier foods as a whole. By starting from our current dietary baseline rather than from scratch, Health Canada immediately abandoned the option of simply using the best available medical evidence to recommend diets that minimize the risk of chronic disease development.

    There are many examples of how this modeling can go wrong because the simple fact that Canadians eat a lot of red meat, potatoes and refined grains don't make them healthy choices.

    To illustrate what I mean, let's take a closer look at a food too rarely singled out - potatoes.

    Over 40% of the vegetables consumed by Canadians are potatoes, and of that 40%, over half are in french fry or potato chip form. Therefore according to Health Canada's formulas, in their test diets there is a 40% probability of potatoes being included as a vegetable choice. There are indeed nutrients in potatoes, but the question that's more important to ask is, "Is there any risk in eating a lot of potatoes"?

    The answer is certainly yes.

    It's a certainty firstly because half of the potatoes consumed by Canadians are fried.

    It's a certainty secondly because ample evidence exists to suggest that high potato consumption has risk. Potatoes increase blood sugar and insulin levels nearly as fast as pure white table sugar which is potentially why in a 20 year study looking at 84,555 women there was an increased risk of type II diabetes in women with higher potato consumption.

    Dr. Walter Willett, the chair of nutrition at Harvard since 1991 and arguably the most important nutritional epidemiologist in history has this to say about potatoes in his exceptional book, Eat, Drink and be Healthy,
    "More than two hundred studies have shown that people who eat plenty of fruits and vegetables decrease their chances of having heart attacks or strokes, of developing a variety of cancers or of suffering from constipation or other digestive problems. The same body of evidence shows that potatoes don't contribute to this benefit. Potatoes should be an occasional food, eaten in modest amounts, not a daily vegetable."
    Without a doubt, the Food Guide's take on potatoes should be to recommend their minimization in your diet. Guess what? It doesn't.

    By modeling off our current dietary choices, healthier food recommendations will be ignored simply because current Canadian eating patterns meet the dietary reference intake patterns for micronutrients.

    Problem is, our current level of understanding of the effects of diet and chronic disease prevention is much more about the foods we eat rather than the nutrients we consume, which is why it would be worth recommending that we minimize foods such as potatoes rather than simply rate them by micronutrient content and worse still, popularity.

    Tomorrow: At Least You'll Get Enough Zinc - Health Canada cares a lot about nutrients...not so much about foods. Last time I checked, I eat foods, not nutrients.

    Big Food Has a Seat - Health Canada's bizarre inclusion of the Food Industry in the shaping of the Guide.