How to talk to your doc about nutrition

Iatros (a patient) 480-470 BC. Good thing medicine has evolved since then.

Let’s say you have finally turned your back on the “calories in = calories out” drivel, donated the hearthealthywholegrains to the neighbourhood birds where they rightly belong and swapped your industrial seed oils, masquerading as vegetable derivatives, for good old-fashioned butter. You feel great, you are losing extra weight, you have reduced your medications and enjoying a healthy relationship with food for the first time in your life. Proud, you announce to your family doctor that you now eat like a caveman and in return you get a blank look with a hint of concern for your mental and physical wellbeing.

What do you do?

Disclaimer: I’m not a general practitioner, PCP or a specialist (yet!). I’ve spoken to many and been taught by a few. As a pre-intern and before, a medical student, I have been a part of the treating team in general practice, outpatients clinics and in the hospital setting. On that basis, I will take the liberty to draw some tentative observations and give some generic advice on this subject. Health professionals reading this, please feel free to chime in.

If you just want to rub it in to your doctor’s face because you have had a tough relationship with the medical profession in general, I get it. You can stop reading now ….

However, if you are intending to maintain a mutually respectful and useful relationship with your GP and even educate them about a couple of things, you might need a few hints.

1. Don’t make assumptions

This might sound obvious but you shouldn’t assume that all docs are stuck in the dark ages and will be naturally resistant to anything out of mainstream. If you are working yourself up for a confrontation you are going to get it. If you expect an open mind from your doc, you need to approach that conversation with an open mind yourself.

2. Don’t accuse the doctor of ignorance or incompetence

It mightn’t be a good idea to start the talk with: “You know nothing about nutrition, I read this blog from a medical student that says so”. May I also refer you to my other post where I point out how many years medical training actually takes.  It’s deplorable that nutrition is not part of the curriculum but it is hardly the fault of a person in front of you, who has studied 12+ years and might have x years of experience. Tread with caution.

3. Be careful with conspiracy theories

We all know about pharmaceutical, agricultural and political interests involved in the business of food supply. But as a conversation opener it really sucks.

“Doctor, I have stopped eating wheat because Monsanto’s unethical practices compromise the health of the planet”
“Riiiight… Erm, have you been under a lot of stress recently?”

4. Bring science to the table

Whether you are a science guru or a curious web wanderer you can use Evidence-Based Medicine to your advantage. If you have access to studies and a deep desire to educate your doctor in the error of his/her ways there are a couple of things you can do.

~ pick your battles: choose one area at a time, eg. Saturated fat is a necessary part of human diet, not a killer substance designed to punish us for our gluttony
~ find the evidence: doctors prefer randomised controlled trials and meta-analyses, like this one:
~ bring a hard copy to the consultation. Emails are less likely to be read as most GPs are very busy. Even better, highlight the abstract of the article and leave the paper for your doc to read. They might or they might not. A simple overview will go a long way to spike their interest:

“Hi, doc, I’ve come across a recent study you might be interested in. Looks like they analysed 21 prospective cohort studies with a total of almost 350 thousand people with a follow up between 5 and 23 years. They found that there was no link between saturated fat intake and risk of coronary heart disease, stroke and cardiovascular disease in general. Seems to be one of several studies in the last 10 years that exonerates saturated fat. Me, I’ve never liked that low fat yoghurt, they just replace fat with sugar. Here is copy if you want to check it out”

~It’s ok if you are not well-versed in the intricacies of Evidence-Based Medicine. Many bloggers out there pull out the latest studies and break them down for those less time/inclination/patience (PubMed…yawn) making a job easier for you.

5. N=1 is a great start

Your results are the best proof that your Paleo/primal/traditional/low carb lifestyle works. You will see the new respect in your doctor’s eyes when they see a drop in your blood sugar numbers if you are a diabetic. They will join you in rejoicing when your long-standing eczema, for which they have written countless steroid cream prescriptions, goes away. “MY irritable bowel syndrome is better now that I don’t eat bread or pasta” might even get your doc interested enough to read that study on gluten that you have printed out for them. Don’t underestimate the deep (sometimes very deep) desire of most doctors to help people and see them get better. They might even suggest a similar strategy to another patient of theirs with the same problem.

6. Admit it: you are a freak

If you think that it is normal to read 5 blog posts a day on nutrition, follow 200 health professionals on Twitter or know the difference between fructose and sucrose, I hate to break it to you. It isn’t. You are officially a part of 0.01% *of the population who a) care about their health b) seek out information c) use their brain d) dare to question the conventional advice. You are a rare breed.

*no actual statistics was used to determine this number. Please do not send emails requesting scientific references

The majority of patients are not like you. They want an instant result with little effort on their part. I do not blame them: they have been conditioned to believe that everything can be solved with a pill, a surgical procedure, a new face cream and an AbCirclePro.

Do you know what most doctors think about lifestyle change recommendations? It’s not that they don’t work. It’s that people don’t follow them.  The frustration leads to indifference. Like many patients, I have issues with the advice to “just eat less and move more”. But sometimes doctors have to deal with people unwilling to stop injecting IV drugs, smoking cigarettes, drinking a bottle of scotch before lunchtime and feeding KFC to their one-year olds. You might just rekindle a jaded doc’s belief in the power of good.

7. Go for the young’uns

Medical students and junior doctors get picked on. A lot. If you survived medical school with your ego intact, congratulations, you must have started at a higher baseline than me. Maybe this is why, in my experience, young doctors are much more likely to admit that they know nothing about nutrition. And why they tend to defer to government guidelines, dietitians and nutritionists. Another reason why the young docs are “an easy target” is because they are still relatively uninfluenced by the pharmaceutical propaganda. They are still naively excited by free Viagra pens. So don’t be afraid to share your experiences and ideas with medical students and hospital residents. Sure, you might get a funny look and a sneaky PRN order for haloperidol (sorry!). But one comment may be all it takes to plant a seed in someone who can look at the system with fresh eyes.

Adult circumcision. Wall painting from Ankhmahor, Sakkara. 2350-2000 BC The oldest known illustration of circumcision.

Doctor-bashing is practically a national sport nowadays. You can always count on an after-dinner horror story about corrupt GPs handing out antibiotics like candy, inept hospital interns missing blood vessels and arrogant surgeons leaving objects in body cavities. If you have decided to turn your back on the Western medicine you might have a good reason for doing so. But if it’s just a knee-jerk reaction born out of frustration with the system and a couple of bad apples, I might be able to convince you to reconsider. And at the end of the day, even if you cannot find the doctor who is willing to let go of the fat phobia or recommend kimchi for healthy gut, the next best thing is a doctor who treats you with respect, empathy and is prepared to listen.

My Whole30 experience

This is going to be a pretty personal post so if you are after something scienc-y call back next week or go and geek out on the amazing series on time from New Scientist (free rego required but worth it).

Most readers here would have figured out by now that I follow a traditional primal/Paleo-ish diet based on high quality animal products, vegetables, nuts, berries and some high fat dairy. Being a part of this Paleo Internet community is amazing but I think sometimes we lose touch with the nutritional reality out there. Let’s face it: the majority of our population still believe that low fat yoghurt plus a cereal bar is a healthy afternoon snack (my rant on the big picture here). I think it’s preposterous and hilarious that my diet is viewed as extreme by those who regularly ingest food-in-a-box with ingredients that you need a degree in biochemistry to pronounce. Yeah, and I’m the weird one.

A few people who in my view do a fantastic job of bridging the gap between the real world and the real food world are Whole9Life, Diane from Balanced Bites, the original caveman Robb Wolf and Mark Sisson. What I like about them is that they recognise that most people need a simple and practical approach to changing their diet and lifestyle. I chose to do a trial run of a 30 day program The Whole30 by Melissa and Dallas Hartwig of Whole9life.

My goals for my Whole30

Weight loss was not a priority for me. I’m pretty petite and in a normal weight range but definitely not skinny. Some days I wish I looked the way I did a few years back in ‘teen % body fat (yes, I was vain enough to get it measured) but then I remember that I was running myself to the ground by training, teaching in the gym, studying and looking after my family. I ended up with some serious overuse injuries which took me out of action for more than a year. Perspective.

Although I’m Russian I am not a big drinker (despite constant references to alcohol on Twitter!) I enjoy my glass of red wine with dinner and it is about all I can normally manage before getting a bit giggly. However since our trip to Italy earlier this year I have noticed myself having wine most nights and also ordering a bottle for 2 at restaurants. Not that I was concerned but I was curious how I would go without alcohol for a month.

The only other tweak that I had to make on my Whole30 was to say au revoir to high fat dairy. I’m a bit of an artisan cheese fiend, sour cream fan, Greek yoghurt addict, you get the picture. I was interested to self-test the theory that dairy has insulinogenic properties exceeding its carbohydrate content and to see if it affects my overall wellbeing.

Impressions

The Whole30 Guide which Melissa and Dallas kindly sent me was easy-to-understand but comprehensive. It would be suitable for both rookies with little nutritional knowledge and hardcore jaded cynics like me. The science was solid but not overwhelming. I like the good cop-bad cop approach: they encourage people to try new foods, listen to own bodies (a skill many forget they possess!) and forgive indiscretions but at the same time tell you to harden the f#%^ up for 30 days. The Facebook page is great to get perspective from other peeps on Whole30 or to ask a direct question. And in case you wondering at this point, no, I’m not getting paid for this.

I was surprised how easy it was to give up alcohol. I just seamlessly replaced my glass of red with a glass of sparkling San Pellegrino and I didn’t miss the wine one bit. In the whole month I had a glass on two celebratory occasions but I checked with Dallas on Twitter and he gave me a-ok :) Now that Whole30 is over I re-introduced red wine but I feel like it has reclaimed its place as a special occasion drink a couple of nights a week rather than a staple.

I wasn’t so lucky with dairy. I hadn’t realised how much I relied on my sour cream, yoghurt and cheese for my fat sources. My downfall at the end of the first week was probably due to my failure to plan other fat sources like coconut oil/milk, avocado and fattier cuts of meat. 5 days into this lowER fat state my brain cells went into meltdown. My mood started zigzagging in step with my food intake (my partner had the lucky foresight to go overseas for that week), I had a couple of spectacular afternoon crashes requiring a nap and the old friend hunger reared his ugly head. Oh, hello, I remember all this. That is what I used to feel like every day when I conscientiously adhered to the Heart Foundation diet high in whole grains and low in fat. Anyway a few rescue tweets and Facebook messages later, I was back on track armed with cans of coconut milk, a few avocados, casserole beef cuts and nuts.

Surprisingly enough, I still found myself a little hungrier than usual for the rest of the month. I attribute my dairy tolerance (some would say dependence) to my Eastern European genes (epigenetics counts, people!).  I didn’t get any digestive upsets when I re-introduced some natural yoghurt back into my diet and it completely solved any niggling hunger issues. However I feel a lot more confidence in controlling my soft cheese cravings and also haven’t felt the need for more high fat dairy since.

An unexpected benefit of focusing more on what I eat and how I feel daily was an appetite for more vegetables. I’m not a big veggie eater. I allow that they might be good for us and generally eat them drowned in butter but I resent the ad nauseum push for 2+5 as if the lack of fruit and veg is the sole source of all our heath problems. That said, on the Whole30 I found myself looking for new varieties at the grocer and doing some veg experimentation in the kitchen.

So at the end I reckon even a pretty good diet can do with a few tweaks. It’s easy to get into a rut with your food choices and the Whole30 allowed me to bring a little more focus and awareness to my food choices.

Anyone who is still on the fence about giving up grains, sugar and industrial food should seriously consider a 30 day program like this. I really believe that cold turkey is the best approach when comes to diet for most people: better struggle for a couple of weeks than drag it out for months and fight the recurrent cravings.

Feel free to share your experiences with Whole30 or your own story of lifestyle change. How did you do it? What mistakes did you make along the way and how did you deal with them?

“Something is rotten in the state of Denmark…”

Edwin Booth as Hamlet, 1870. Source: Wikimedia Commons

Ah, Marcellus, something certainly is not right in the fair state of Denmark as of last Saturday. In case you have missed the hullabaloo in Europe, a new surcharge, colourfully dubbed by the press “the fat tax”, took effect in this small Scandinavian nation on October 1, 2011. As usual, it didn’t take long to generate a massive media hysteria. After reading over 20 reports on the internet and getting thoroughly confused by factual contradictions I managed to pull out the following info:

  • the tax applies to all foods containing >2.3% saturated fats
  • each kg (=2.2lbs) of saturated fat will collect a surcharge of 16 kroner (=$US 2.87)
  • the tax is introduced as part of obesity-fighting measures and $218 million US dollars expected to be raised will go towards preventative health
  • the goal of this intervention is to reduce saturated fat intake in Denmark by 10% and butter intake by 15%

As this article eloquently puts it:

“The new tax will be levied on all products including saturated fats, from butter and milk to pizzas, oils, meats and pre-cooked foods…”

Interestingly, Copenhagen Post was seemingly concerned about other foods items:

“The biggest price increases will be seen on fatty staple foods like butter, oils and high-fat dairy products like whipping cream and crème fraiche…”

Let me for the moment pass over the ridiculousness of the sentence which lumps an ancient traditional product like butter together with pizza and pre-cooked food-like-substances-in-a-box. To be perfectly honest, I know very little about Denmark. My impressions largely consist of Vikings, dams, environmental activism, Princess Mary, beautiful images of Copenhagen and yes, butter. So after 4 days of self-imposed post-exam laziness I got my iPad out and started reading up on the Danish health, economy, agriculture and food consumption.

Warning: a few graphs coming your way.

First a few Denmark trivia facts (Source: NationMaster.com country statistics)

1. The population estimate in Denmark today is over 5.5 million with population density of 129 per km2

2. According to the latest WHO data (2008) the actual obesity rate in Denmark is 18.2% not 10% as widely reported

3. Danish Big Mac Index is the fourth highest in the world at US$4.49

4. An average Dane goes to 6.1 doctor consultations a year

5. The life expectancy at birth is 77 for men and 81 for women, lower than in Finland, Sweden and even Australia (in your face, Danes! Even with our diabetes-crippled legs and sky-rocketing obesity rates we live longer!)

6.The average tax burden is 46%

7. Denmark is widely considered one of the happiest and least corrupt countries on the planet (not sure how it tallies with both #5 or #6 but good for them)

The World Health Organization updates a regular Non-Communicable Diseases profile for each country. You can look Denmark up here. Allow me share a few more interesting facts from that profile.

I was surprised to note that 24.6% of Danes still smoke cigarettes daily, a figure much higher than 16.8% of smokers in Australia or 15.6% in the US. If I had to choose a public health intervention…

Let’s take a look at the trends of some chronic disease markers as defined by the WHO: BMI, fasting blood sugar, systolic blood pressure and total cholesterol.

Blue line = men, orange line = women

Both average BMI and fasting blood sugar have been steadily climbing. That’s clear enough according to public health warriors. Butter -> extra calories -> overweight -> diabetes. This is how the conventional wisdom goes, n’est ce pas? Strangely enough, both systolic blood pressure and total cholesterol have decreased in the same period of time:

Obviously, this is just observational data and it doesn’t offer any causative relationship. Correlation does not mean causation (repeat this statement like a mantra if you work in public health). It could be that while the Danes still enjoy their high-fat dairy and meat their busy physicians prescribe them lots of antihypertensives and statins. If only we could get the Danish public to reduce their wicked butter and cheese habits, increase their intake of whole grains and vegetables and bingo! we would see those numbers plummet, life expectancy jump up, muffin tops melt away, relieved cows will be doing a happy dance.

Luckily my curiosity didn’t stop there. I wanted to see just how gluttonous the Danes apparently are. (Clarification: I don’t think they are gluttonous. As far as I’m concerned their government tells them that they are. I’m just following that logic). Statistics Denmark  kindly provides all sorts of fascinating data free of charge. I pulled out some food consumption data in Denmark and ran a comparison between the years 1990, 2000 and 2009. And in case you are wondering, I totally cherry-picked my data, using only 13 out of available 55, just because I found them most illuminating but you can look up the raw data yourself here StatBank Raw Data. Click on the chart for better resolution.

 

Human consumption kg per capita per year

Turns out that our butter-loving Danes are not eating that much butter after all: only 1.9 kg per person per year. So a desired 15% decrease in butter intake will result in…drum roll…1.6 kg per person. They consume 4 times more margarine than butter however thankfully their margarine consumption has also been declining in the last 20 years. What else can we see? Overall reduction in meat consumption since the 1990: 105.2kg to 83.6 kg. They certainly eat more beef and veal (18.8 → 24.8) but almost halved their pork consumption (64.2 to 35.8). Offal consumption is less than half of what it was even 20 years ago. In keeping up with the low fat trend, whole milk dropped 65% while white water, pardon me, skim milk jumped up over 400%. We have some increases in wheat flour and other grains, including a dieter’s staple, oats.

The other numbers that we are all dying to see are of course soft drinks (soda), industrial seed oils, sugar and the one I was always wondering about, a humble coffee shop favourite, the danish (do they even eat those?).

Overall Denmark looks like an awesome country: rich history, friendly people, gorgeous architecture. It’s a shame that their outgoing government in the desperate show of “we really care” brought a ridiculous tax which promises so much but delivers nothing other than panic at the supermarkets and more guilt about eating butter. I’d still love to come for a visit but next time I’ll bring my Lurpak from Australia.

What the @#$! do I feed my child?

A blackboard used by Albert Einstein in a 1931 lecture in Oxford. Source: Creative Commons

I find maths and science quite soothing. There is something beautiful about straight numbers and clear cut conclusions. You must have already picked up on my love of graphs and diagrams. They got me through med school.

However, once you finish a beautifully straightforward equation or reach a perfectly logical conclusion using an algorithm you hit a little snag. How do you translate all these numbers to real life?

In the last few weeks I have read somewhere around 30+ journal articles on child metabolism alone. The numbers are simple, the graphs are straightforward but as we very well know the applications to child nutrition can be vastly different. For all the parents out there the only biochemical pathway they are likely to be interested in is the one between the fridge and the pantry.

Here is a short summary of my last few slightly dry posts on child metabolism (on conventional advice, BMRmalnutrition and catch up growth) and MY conclusions.

1. Children grow. Therefore children are not in “energy balance” in simple terms. The energy cost of growth is high including both the energy density plus quality nutrients to ensure lean body mass increase.

2. Energy quantity (calories) is important but ultimately you cannot build muscle and bone with broccoli or worse, orange cordial. The quality of nutrients needs to be concentrated to provide more bang for your buck: high nutrient density in a small volume fit for a small stomach.

3. Children regulate their energy needs with their appetite. No calorie calculators required. When the nutrient quality has been addressed the appetite will take care of the rest. If they are hungry they will eat.

4.  Babies, infants and children have less reserves to cope with malnutrition. Even a minor infection may potentially result in muscle loss.

5. Point 4 makes it obvious that it’s not a good idea to put children (=growing bodies) on calorie restricted diets for weight loss.

6. A decrease in activity is a pretty good marker for malnutrition especially for small children. This should give some worried-well parents some confidence, especially where breastfed babies are concerned. If you baby is happy and active it is likely that they are getting enough energy.

7. When children recover from even a minor infection their energy requirements are 4-5 times what they were before. They are going to be very hungry. Feed them. A lot.

8.The period of catch up growth during recovery puts children in a slightly vulnerable metabolic state. They seem more likely to develop insulin resistance (in skeletal muscle), sensitivity to glucose and store abdominal fat.

9. Point 8 makes you think that the post-recovery window is crucial for providing good nutrition for longer term gains. Maybe it is not a good time to provide sweet treats or let children laze around. My thoughts go towards fatty chewable chunks of meat and providing plenty of opportunities for spontaneous activity.

10. My personal way of identifying junk food: if a child is willing to have it after a steak dinner it’s junk. Nobody makes room for more meat or pumpkin when they are stuffed. But there is always stomach space to be found when lollies, cakes, milkshakes and ice-cream are on offer.

The diet recommended by our health authorities always confuses me. I assume (perhaps naively) that they read the same studies and they study the same physiology books. I’m stumped at how they arrive at their conclusions. Today Cancer Council NSW, backed by the Obesity Policy Coalition and the Parent’s Jury, announced the latest villains in the child obesity epidemic: Toucan Sam

and the Paddle Pop lion:

The research by Cancer Council NSW and the University of Sydney found  that 74% of supermarket products adorned with bright cartoon packaging are not up to our healthy nutritional standards. The specific complaints were high-sugar, high-salt and high fat. Apparently the adorable visages of cartoon characters and chiseled jaws of our sporting heroes are just too much for the little kiddies (and their parents) to resist.

“Although stopping short of calling for plain packaging (???) Cancer Council nutritionist Kathy Chapman said regulations around the marketing of foods to children were urgently needed.”

Deep breath. I am not defending sugary cereals. (Not entirely sure how the high-fat monster has slipped into the discussion since the foods in question are mostly low in fat to the point of deficiency. But that’s another matter). In fact, I’m happy to wear a t-shirt: “Friends don’t let friends eat cereal”.  I am more concerned about the whiff of a new scare campaign and propaganda. Plus, when it comes to my own child, I’m the one with a wallet, sorry kiddo.

The second issue is that we rely on these guys for their interpretation of science to tell us which foods are healthy and which are not. I hope we all agree that Froot-Loops are not exactly health food. Nobody buys those because they think that the multiple colours are indicative of the high antioxidant and phytonutrient content. On the other hand Kathy Chapman “welcomes cricketers fronting Weet-Bix” presumably because she thinks that this brand of bland cardboard-like blocks of processed wheat is a healthy alternative. Never mind that most children cover it with malt, sugar, fruit and honey just to make it palatable.

And because the University of Sydney (the home of GI) is involved in this story I’ll throw in a GI reference:

Froot-Loops 69
Weet-Bix 69

Ha.

P.S. I have a very special guest post coming up for you next time. The guest is currently in the middle of the creative process and I am not sure how long before we see the final result. But I know it is going to be something.

Catch me if you can

Before my foray into the world of celebrities I was talking about babies, children and the effect that illness can have on their metabolism. I have also alluded to something called catch up growth and the fact that it might be important for the overall risk of obesity and chronic disease.

What is catch up growth? The medical dictionary defines it as:

“…an acceleration of the growth rate following a period of growth retardation caused by a secondary deficiency, such as acute malnutrition or severe illness…”

The easiest way to track catch up growth in visual form (and you know that I like my visuals) is on growth charts. Children tend to follow an individual growth curve, predetermined largely by genetics, and this phenomenon is called “the canalisation of growth”. As we have established in the previous post, an illness or or a period of malnutrition may result in falling off the curve. Catch up growth is the body’s attempt to get back onto the original curve.

Growth curve flattening and fall (example only)

Accelerated growth during recovery phase

It has been known for quite a long time from observational studies that babies and children who undergo a period of catch up growth seem to be at higher risk for obesity and diabetes later in life. This was also observed in children born small for gestational age (SGA),  which is an indirect indicator of fetal malnutrition. Similar phenomenon was noted in children growing up in famines (the Dutch famine study) and the survivors of the Leningrad blockade in the WW2.

Studies conducted in the 60’s and 70’s looked further into the energy metabolism of catch up growth. They showed that the rate of growth in these children is astonishingly up to 15-20 times the rate of normal pattern. Moreover, this period was accompanied by both increase in appetite and increase in BMR in the order of 4-5 times the controls. It seems that when children were fed ad libitum they spontaneously increased their food intake to ensure their bodies get back on the curve. As their weight approached the expected measure for height their appetite would decrease back to normal levels.

Another interesting observation made around 1980 was that children do not regain lean body mass at the same rate as they lose it. Muscle recovery lags behind the recovery of fat tissue even when children regain their weight and get back on their growth curve. As one of the studies frames it:

“The impressive gains in weight made by recovering malnourished infants are largely fat; reconstitution of lean tissue does not occur equally well at all rates of weight gain.”

Let’s go back to some visuals or rather my illustration of the above.

Body composition changes during illness and recovery

The greater degree of the initial weight loss, the more unbalanced the pattern of catch up growth.

Later research started to elucidate the mechanism by how this imbalance occurs. Several studies have identified that the phenomenon of catch up fat is accompanied by hyperinsulinaemia, relative insulin resistance in skeletal muscles and hyperresponsiveness to insulin in adipose tissue.

Basically, when the child is recovering from a period of malnutrition their bodies produce more insulin for the same amount of glucose. Their muscles “shut down” the insulin gates and their fat tissue opens the gates wide so that glucose is shuttled away from the muscles and into fat.

Some of the more recent studies have tried to explain this phenomenon using terms like “thrifty gene”. Since no such gene has yet been identified to my knowledge I’m a little unconvinced. What interests me however is whether this slightly worrying pattern is diet-dependent. In other words, what do you feed a sick malnourished child to prevent this from happening? Is there a single dietary cause? What did all these children in observational studies eat?

Looking for causes in cohort data is always a fruitless exercise and a reminder that we should use it to generate hypotheses only. Randomised controlled studies on actual babies are obviously out of the question, I doubt there is an ethics committee on earth which would agree to withholding food from children and then watch them lose and then regain weight on various dietary regimens. There are always rats but they have an obvious disadvantage of being…well, rats.

One zealous study examined the rats undergoing catch up growth after semi-starvation. Those re-fed a high-fat diet were found to have more hypinsulinaemia, higher fat deposition and lower metabolic rate than the rats fed a low-fat diet. Both re-fed groups had worse metabolic derangement compared to controls. A closer attention to the high-fat diet tells you that the rats were fed 1:1 corn oil:lard mixture as 50% of their diet. What does it tell you? That it’s not a good idea to feed rats 25% of their diet as corn oil. Not much else really. It also makes it clear that both re-feeding diets resulted in higher insulin response to the same glucose load, higher adiposity, lower thermogenesis and other markers of disordered metabolism.

So we are back to generating hypotheses.

Recent developments implicate a group of messengers called IGFs, insulin-like growth factors. A series of experiments on none other than zebrafish showed that low cell oxygen level as would occur in malnutrition or disease can disrupt IGF signalling which activated the MAP kinase pathway, necessary for growth. Restoring oxygen to the tissues did not always result in full system reboot. Pathways other than MAP kinase may be activated which could explain the different growth pattern. Sigh… let’s wait for the zebrafish to give us the answer.

While you are digesting all of this info I will put together my take on some of these fascinating issues. Of course, I could be the only one who actually finds this stuff so intriguing and you might be going about your day without giving the concept of catch up growth a second thought. But I reckon some of this might still apply to you whether you are a determined bachelor or a mother of four. What if you were the one who had a prolonged illness at some point in your childhood? What if this pattern of metabolic disregulation also applies to the yo-yo dieters amongst us? Aha, now you are thinking about this.

Look out for my summary post on child metabolism in the next couple of days.

More reading:

Ashworth A, Milward DJ, Catch up growth in children (1986) Nutrition Reviews 44(5):157-163

Jackson AA, Wootton SA, The energy requirement of growth and catch up growth, Proceedings of an I/D/E/C/G Workshop held in Cambridge, USA 1989

Dulloo AG et al, Pathways from weight fluctuations to metabolic diseases: focus on maladaptive thermogenesis during catch-up fat (2002) International Journal of Obesity 26(S2): S46-S57

Ong KKL et al, Association between postnatal catch-up growth and obesity in childhood: prospective cohort study (2000) BMJ 320:7240

 

 

“Dangerous habits” of celebrities

I’m still doing research and writing on children and catch up growth. This is a just little interlude.

Source: Wikimedia Commons

I have never thought I’d be writing a post about a celebrity. I’m not very celebrity-savvy mainly because I don’t read women’s magazines or watch much TV. I have only just found out that there is a person out there named Snooki and apparently she is as famous as Meryl Streep. I’m still perplexed about this but it just shows you that I’m way behind the times.

However, I know a few things about Miranda Kerr. She is Australian, she is gorgeous, married to Orlando Bloom (I hope my readers over 35 know who he is) and she is a Victoria Secret model. Not my typical blogging subject but bear with me. She first came on to my nutrition radar when she recently had a baby and continued to be remarkably sensible about it. Miranda was breastfeeding right left and centre and seemed hellbent on doing it well past the obligatory couple of months of breastfeeding for a celebrity. I was writing a few breastfeeding posts at the time and was impressed in spite of myself.

Miranda caught my eye again recently when she got into some hot water about eating coconut oil. Those of you in the Paleo world and my long time readers know that coconut oil is mostly made up of saturated fats, in particular MCTs (medium chain triglycerides). I first heard this story on the news. Yes, I know, a celebrity giving diet advice somehow makes the evening news. This is how it went down.

About a week ago the world of fashion, beauty and Botox went into meltdown when reports were published of Miranda Kerr “revealing her beauty secrets” to Australia’s Cosmopolitan.

I’ve been drinking it since I was 14 and it’s the one thing I can’t live without…I will not go a day without coconut oil. I personally take four tablespoons per day, either on my salads, in my cooking or in my cups of green tea.”

Big, big mistake, Miranda. You see, if you only followed some normal garden-variety weird celebrity diet and exercise plan nobody would have batted an eyelid. Look how many options you had available!

“Being vegan – eschewing all animal products – is a pretty hard slog.  But you can’t deny that it’s good for the environment, and good for our bodies, too.’
“Colonic irrigationist to the stars (yes, this is somebody’s actual job description) recommends Quintone, naturally harvested from oceanic vortex plankton blooms, it’s taken in liquid form and comes in a vial. It’s purely organic and is never heated, meaning that it is accessible by the human body: it’s easily absorbed in the intestinal tract, ie digestible.”

“BENEFIBER: This powdery fibre substance is flavourless but it packs a punch. Celebrities put it in their coffee or sprinkle it on their salads as it helps move food through you system more quickly.”

So in the world of the wacky, surely, Miranda’s “coconut oil habit”, as it was described by some of the media, is not much of a big deal? Not so. As we know many people feel very uncomfortable about saturated fats, and even more uncomfortable about the possibility of saturated fats being good for you. Subsequently, the attacks had a whiff of pathetic desperation.

The headlines went ballistic:

Doctors slam Miranda Kerr’s coconut oil habit
Experts warn against Miranda’s coconut oil habit (you’d think they were talking about cocaine!)
Experts doubt coconut oil will give you a body like Miranda Kerr’s (d’uh)
Miranda Kerr touts coconut oil, experts baulk
Habit harmful
Hollow promise

Wow, some strong words there. This stuff must be truly poisonous. Let’s see what the experts had to say.

“But experts said the oil, which is a saturated fat with a high calorie count and few vitamins and minerals, should not be consumed in such large doses, ABC News reported. The World Health Organization has also warned the oil could contribute to an increased risk of coronary heart disease if taken to excess. Keith Ayoob, director of the nutrition clinic at the Children’s Evaluation and Rehabilitation Center at the Albert Einstein College of Medicine, said the oil will not give you the body of a supermodel.
“She’s getting two and a half times the amount of saturated fat I would recommend for a person consuming 2,000 calories per day,” he said.
Dr. Robert Eckel, director of the General Clinical Research Center at Colorado Health Science University in Denver, also expressed concerns about the effect of the oil on a person’s cholesterol.
“Saturated fat intake does contribute to LDL [low-density lipoprotein] cholesterol, and that has been pretty well documented by research,” Eckel said referring to “bad” cholesterol.

Now I’m not advocating to listen to any celebrity for diet advice. But in Miranda’s defense:
1. She didn’t advocate that everybody does it
2. She is not talking about injecting bacterial toxins or getting a surgical cut to insert silicone balloons in her chest. It’s a natural product and a big part of the traditional diets of the Pacific populations, for crying out loud.
3. There are plenty of experts out there who will be willing to bet their career that coconut oil is good for you. Wonder why nobody interviewed them.

A few days ago Miranda put this message on her personal blog (the blog which incidentally has articles on organic farming, milk alternatives and gluten-free food) :

“I never did an interview with Australian Cosmopolitan magazine and unfortunately they have misquoted and misrepresented comments posted on my blog. When it comes to coconut oil, I personally find it beneficial and use approximately four teaspoons of coconut oil a day (in my salads and meals), not tablespoons. Everyone is different, but that is what works for me and I prefer it as a substitute to other oils more readily used in day-to-day food preparation and cooking. I suggest people consult with their health practitioner for what is right for them.”

Miranda’s perfect complexion might be good enough reason for some to indulge, albeit guiltily, in some coconut treats. For those of us who prefer more convincing arguments, here are some easy-to-read sources that are good to share with your fat-phobic friends.

1. Mary Enig PhD “Latest studies on coconut oil”

2. B.F. Fife “Coconut oil and health” Page 49 from “Coconut revival:new possibilities for the “tree of life” Proceedings of the International Coconut Forum 2005

3. Coconut Research Centre (also contains a collection of scientific articles)

4 G.Taubes “What If It’s All Been a Big Fat Lie? ” the original and still the best article on anti-fat hysteria

Down the slippery slide we go!

J.Waterhouse "A sick child brought into the Temple of Aesculapius" 1877

Continuing from my last post about metabolism in babies and children, today I will address what happens when a child goes through a period of inadequate food intake.

Viral or bacterial infections, prolonged hospital stay and chronic disease are some of the common causes of temporary malnourishment in Western children. Frank underfeeding is fairly rare though it still happens in certain extreme dietary lifestyles. While there are definitely differences between chronic malnutrition (the kind we associate with “the starving children in Africa”) and a week-long diarrhoeal illness in a typical Australian child, there are many similarities.

A few older studies (they weren’t too hampered by ethical considerations in those days) examined underfeeding in babies and children in some detail trying to establish how the body copes with the lack of energy and nutrients.

If you remember from the previous post, energy intake in children accounts for their BMR (basal metabolic rate), activity and growth.

Intake = BMR + Activity + Growth

As it turns out, the body puts a different priority on each of these components. Survival (BMR) comes first followed by Growth and then Activity. As a consequence, a malnourished child will first decrease activity levels.

If reducing energy expenditure does not compensate for inadequate intake then growth becomes affected. Within growth 2 parameters are easily measured: height (length in infants) and weight, both can be tracked along growth centiles on standard growth charts. A prolonged illness might result in the slowing of weight gain which will be reflected in drop down a centile. Weight loss comes both from fat loss and muscle loss. While the organs are relatively protected in minor illness, the muscle mass is not.  Catabolism (breakdown) of muscle tissues has been reported even after measles immunisations and asymptomatic Q fever.

A profoundly malnourished child will also slow their height velocity possibly resulting in stunted growth.  All of the above will happen way before the metabolic rate of individual organs is affected.

Sequence of metabolic events in malnutrition in childhood

Reduction in activity in a malnourished infant may be subtle to the outside observer. The child does not necessarily lie motionless and exhausted in her cot but they might be less vigorous and inquisitive. An interesting study was conducted back in 1979 in a Mexican village. The investigators followed two groups of children: one was given supplementation of vitamins, minerals, strained foods and milk (in fact the diets of their mothers were supplemented in pregnancy as well), the other group was not. Supplemented babies were more active, cried less, spent more time out of their cribs. In one of the experiments 2 year olds were taken out onto a 3 x 3 quadrangle and their movements recorded for 10 minutes. Investigators recorded the movements of well-fed and malnourished infants. Some toys were placed in one end, their caregiver and two observers at opposite ends.

This is a tracing of the movements of a control child (no supplementation):

Source: Chavez and Martinez 1979

This is a tracing made by a supplemented child:

Whoa, somebody went a little crazy! Obviously the results could be related to both quality and quantity of the food given, better development in better fed infants, an uncertain deficiency in controls or some other factor. Nevertheless it is clear that malnutrition can affect the physical activity of children. One of the first questions a parent is asked by a pediatrician or a general practitioner is: “Is your baby happy and active?” This graph makes it clear why.

Anorexia, or loss of appetite, is something that most parents witness in a sick child. Spontaneous decrease in food intake is well described in scientific literature. What can be simpler: a sick child doesn’t feel like eating and loses weight as a result? However, while anorexia accounts for some of the weight loss, it does not explain all of it.

As I have mentioned before, children tend to lose muscle mass in addition to fat loss during illness. Muscle wasting, the two words that terrify any self-respected gym junkie, is a costly exercise in a child. Body composition is notoriously hard to measure in infants but we know that adipose tissue in 2 year olds can measure between 20-25%. So why don’t the children use their soft cushioning for energy when sick? As it turns out being ill makes it harder for the body to access fat stores. The signals from body’s own hormones and the activation of the immune system causes a switch to protein catabolism and utilisation of amino acids stored in the muscle for gluconeogenesis (creating glucose in the liver for release into the bloodstream).

Another mechanism by which acute disease contributes to the loss of muscle mass is the paradoxical increase in BMR, or hypermetabolism. Mechanisms of this are not entirely clear but it has been recorded across many studies. One of the main suspects is fever. The often quoted figure is the 13% raise in BMR for every 1 degree Celsius above 37° (It comes from an old study by Dubois, 1938, unfortunately I do not have a full text). However, these mechanisms cannot compensate for muscle wasting and decreased organ metabolic rate in chronic active disease and profound malnutrition. Protein can also be lost directly from the gastrointestinal tract via the process called protein-losing enteropathy  due to a variety of infectious, inflammatory or congenital causes.

It may be helpful to think of energy status in malnutrition and disease as a balance between energy conservation and energy loss. The adaptive mechanisms that the body tries to use fail in the face of a serious and/or prolonged illness resulting in negative energy balance.

Energy balance in response to illness

So let’s apply some of these factors to a hypothetical situation: an otherwise healthy 18 month old catches a nasty gastrointestinal bug, like Campylobacter, at his playgroup.

The first sign that something is wrong might be a slight decrease in activity. Vomiting and diarrhoea, energy-draining processes by themselves, prevent nutrient absorption.  Appetite decreases and the actual food intake may stop altogether. Negative energy balance kicks off a conservation response and the child’s activity reduces even more. If the episode is complicated by high fever you can expect BMR to rise slightly. Reduced activity will only be able to compensate the energy deficit up to a point. Laying down new tissues for growth has already come to a halt. By this stage the body may start to break down muscle for glucose and fat stores for energy. The longer this infection hangs around the more muscle is wasted. BMR starts to reduce due to the loss of fat free mass. After a week or two of being unwell you have on your hands a lethargic possibly dehydrated child, with reduced fat and muscle mass and a reduced appetite.

If the adverse stimulus (=infection in this case) is not removed the road to chronic malnutrition with subsequent growth stunting and reduced organ metabolic rate continues. The resolution of infection sends a powerful recovery signal and catch up growth begins.

However, catch up growth pattern is not the same as the normal growth. After taking a step back, the body has to leap 2 steps forward to get back on track. And it seems to have some trouble doing that. In my next post I’ll discuss the catch up growth and how it’s linked to obesity.

If you have children of your own I apologise if this post was a little unsettling. When your baby is unwell the last thing you want is a little paranoid voice in your head whispering about the inevitable lean body mass loss etc. I will discuss my ideas about the optimal nutritional strategies for recovery a little later, I promise.

More reading:

Scrimshaw NS, Energy cost of communicable diseases in infancy and childhoodProceedings of an I/D/E/C/G Workshop held in Cambridge, USA November 14 to 17, 1989

Wiskin AE et al Energy expenditure, nutrition and growth Arch Dis Child 2011;96:567-572

Veldhuis JD et al Endocrine Control of Body Composition in Infancy, Childhood, and Puberty Endocrine Reviews 2005;26(1):114-146

Beisel WR Magnitude of the host nutritional responses to infection, American Journal of Clinical Nutrition 1977;30(8):1236-1247

Energy vampires and other matters

In my last post I talked about the inconsistencies and often the sheer stupidity of some of the nutritional advice we hear on a daily basis. One of the readers made a comment “I don’t understand the point she is trying to make”. Well, actually I’m not trying to send a big message here. My blog is where I write about what I see, comment on it (yes, sarcasm is my way of coping with some of the rubbish) and leave you to make up your own mind. Occasionally I throw a bit of science so you can see where I’m coming from. I do not spend hours doing an exhaustive literature search in Medline (I don’t have that luxury) but I’ve accumulated my fair share of information in the last 8 years of studying science and medicine and especially in the last year of learning about nutrition in particular.  If you see a study that supports some of the things here feel free to send it my way. Ditto if you feel it directly contradicts it.

Anyway let’s get into it. Today we are talking about metabolism in children. This post will be an overview of the basics and probably quite dry and boring. I’ll try to throw in some graphs and cute baby pictures for those who like that kind of thing.

It's been a few years but she still licks her bowl

I love the topic of child nutrition for several reasons. First, I have one of those little people at home so I’m naturally interested in what to feed her. Second, I believe that what you put in your body in infancy and childhood (and possibly even before, in the womb) is going to directly affect your health and size in the future. Third (and favourite), when you talk about child and particularly baby nutrition you take away the so-called “gluttonous sloth” theory of obesity and disease.  It’s ludicrous to accuse a 1 year old of a lack of willpower and laziness, so we are left with the bare bones of nutrition. And more than ever how that little body self-regulates its own nutritional status.

Metabolism (n) – the chemical processes occurring within a living cell of organism that are necessary for maintenance of life.

The Free Dictionary by Farlex

In other words, metabolism is the way your body processes the nutrients you receive with food. It’s tempting to look at food as pure energy but as we know calorie is not just a calorie. Food provides both the energy and the building blocks: 2 components required by each cell to perform its own unique function. In an adult this means you need to take in enough nutrition to provide energy for metabolic processes necessary for pure survival  and also the materials for the continuous repair, regeneration, special circumstances (illness, pregnancy, muscle growth).

In children, one more component is added to the picture = growth. The food they eat has to supply enough energy for basic metabolic processes and activity, building blocks for daily repair and regeneration AND additional intake to allow for growth.

Intake = Basal Metabolic Rate + Activity + Growth

Growth does not just come from extra energy but from extra nutrients required to create/synthesise new tissues. This has a few implications which I want to discuss in more detail later.

What is physical growth? Seems a silly question as this is a phenomenon most of us are very familiar with. We also have an intuitive understanding that different tissues grow at different rates, which accounts for a changed body composition. The body shape transition from a chubby baby to a stocky toddler to a lean pre-teen to the sex-specific changes in adolescence and finally into adulthood is multi-dimensional with unique composition corresponding to each stage.

An average newborn with a weight of 3.0kg (6.6 bs) increases her own weight by over 300% to around 10kgs (22lbs) by the end of her first year. Her brain weight goes from 450-500g to over 1000g in the same period of time, a weight remarkably close to 1400g in an average adult.

If you look at babies’ body composition their perceived chubbiness turns out largely illusionary. The body fat measurements of a newborn average a very svelte 12-15%. The remainder is allocated a name of FFM = fat free mass which consists of organs, muscles, skeletal structure and extracellular fluid. In the table below you can see how body composition changes in the first 18 months: muscle mass and fat mass increase, extracellular fluid decreases. Organ weight increases in proportion to body weight in the first year of life therefore the relative percentage of brain, liver, heart and kidney remain similar.

Adapted from Holliday,1986. ECF = Extracellular Fluid

Basal Metabolic Rate (BMR) in babies is determined mainly by the metabolically active tissues of the brain, liver, kidneys and muscles. The brain activity of a newborn is estimated at a whopping 80% of her BMR, dropping to about 60% through the first year as activity increases and muscle becomes more metabolically relevant.  In addition to organs and muscles there is new evidence that some of the fat mass in babies and children is in form of BAT = brown adipose tissue which is more metabolically active and itself participates in energy expenditure. (Adults have some BAT too but in much smaller quantities).

Distribution of brain, liver and muscle metabolic rates as percentage of total BMR at different body weights (Holliday 1986)

So what have we learned so far?

The energy intake in babies and children has to account for their high relative BMR, allow for activity and also provide the energy for the process of synthesis of new tissues PLUS the energy that is deposited in new tissues.  Once again:

Intake = Basal Metabolic Rate + Activity + Growth *

*For science geeks, I have left out the Diet Induced Thermogenesis for the sake of simplicity and uncertain contribution to energy balance in children

It’s official. Babies and children are energy vampires. This might sound very daunting for the food providers, the parents.  How do you know how much to feed a child to ensure all these processes perform without a hitch? At the same time the growth of most infants follows a fairly predictable pattern. Whether they are breastfed on demand or formula fed by the hour, whether they are weaned onto rice cereal or meat, save for small variations in fat mass their FFM (fat free mass) will be very similar.

Lucky for us, parents, we do not have to hunt around for scientific papers estimating energy expenditure, calculate our child’s activity and measure out every spoonful. Under normal circumstances, babies seem to do quite well without science.

That is when everything goes well. What if it doesn’t? For the first time in human history we are way more concerned with OVERnutrition rather than UNDERnutrition. But it is probably too simplistic to completely separate these two. Next post I will look at malnutrition and the fascinating subject of catch-up growth and what it can teach us about childhood obesity.

More reading:

Veldhuis JD et al 2005 Endocrine control of body composition in infancy, childhood and puberty. Endocrine Reviews 26(1): 114-146

Activity, energy expenditure and energy requirements of infants and children, Proceedings of an IDECG workshop held in Campbridge, USA, 1989

Holliday 1986 Body composition and energy needs during growth. In: Human growth: a comprehensive treatise, 2nd ed. Plenum press, NY 1986

Playing hostage to your child

I was trying to find a picture of a child gnawing on a bone. But apparently it doesn't send the right message

We have all seen TV footage which normally accompanies the “childhood obesity epidemic” stories. Strangely headless muffin-topped children’s bodies in oversized t-shirts, digging into a packet of chips or clutching an ice-cream, filmed walking out of a fast-food joint with their obese parents. You’ve all seen it, right? This picture is remarkably divisive: some of us come pouring out with indignant accusations (“child abuse”, etc), some shrug off the criticism recognising themselves or friends. Dismissing the unlikely scenario that the parents of the 25% of overweight and obese children in Australia really don’t give a toss about their offspring (let’s work on the assumption that most people love their kids) what do we do?

Whether you are a parent or plan to become one some day you might feel legitimately concerned about how to keep your child out of similar news footage.

You might want to do what any responsible parent would do to find information: google it. A cursory search for “healthy eating for children” has yielded a staggering 19 500 000 results. So far so good: almost 20 million ways to avoid being a weight statistic. Encouraging to see so many experts.

But you don’t have to be a doctor, a nutritionist, an organic biochemist or a passionate Paleo convert to know a thing or two about kids. First, they are small. They have small stomachs, small mouths, small hands and small appetites compared to an adult. Second, they are not just “little grown ups”. They have unique needs for growth and development.

Put these two assertions together: high needs/small appetite. That makes me think that we need something nutritionally dense in a small package. Let’s see what the Healthy Kids Association (a very official looking site) says on the subject.

The Dietary Guidelines for Children and Adolescents in Australia (DGCA) recommends that for best health children should “enjoy a wide variety of nutritious foods”.

Why such concern about variety? Sounds like we are calculating that if we cast the net wide enough, sufficient nutrients will hopefully get inside those little bodies.  Every parent knows that extra food volume equals extra drama at the dinner table. If you put 5 different types of veggies on little Johnny’s plate hoping that one of them fulfills the vitamin C quota you might be setting yourself up for failure. It doesn’t look like we are aiming for the bull’s eye: that small package of condensed nutrition. “Eat a balanced diet” is a nutritional equivalent of sitting on the fence. Let’s find something more specific.

According to the official HealthyKids website (I’m sensing a certain lack of originality here) courtesy NSW Government there are 5 ways for your children to be healthy.

1. Get active each day

Sounds great, albeit oddly contrasted with the mantra of the 19th century: “children should be seen and not heard”.  All those quiet well behaved children back then clearly had a weight problem.

2. Choose water as a drink

In the world where soft drinks (sodas) are the daily norm this statement does not sound bizarre anymore.

3. Eat more fruit and veggies

I’m all for fruit and veggies. But what does “more” mean? More than what? Is the total amount of fruit and veggies per day uncapped? And if I could make an objective assessment that my child does not have “enough” you’d think that I would also work out that she needs “more”.

4. Turn off the TV or computer and get active

I thought we have already covered that one. What if you have a Wii-Fit? Does it count as active? Because I think it requires having the TV on? (we don’t own a Wii-Fit, or Nintendo or X-box  so I’m not sure how it all works). Is doing wii-boxing better than doing none? What about those schools that use Wii instead of sport?

5.  Eat fewer snacks and select healthier alternatives

Spot on. What are the healthier alternatives?

Here is a list from the snack page:

Fruit muffins or slices, baked using monounsaturated or polyunsaturated oils and margarine instead of butter
Fresh, frozen, canned (in natural or unsweetened juice) or dried fruit
Raisin or fruit toast
Toasted English muffins, preferably wholemeal or wholegrain
Reduced fat custard with fruit
Rice crackers or corn cakes
Plain popcorn (unbuttered and without sugar coating)
Muesli and fruit bars – look for the healthier choices or those with the Heart Foundation Tick.
Scones or pikelets (plain, fruit or savoury)
Plain breakfast cereals, such as wheat breakfast biscuits, topped with sliced banana with a drizzle of honey
Snack-sized tub of reduced fat yoghurt (plain or fruit flavoured)
Cubes, slices, shapes or wedges of reduced fat cheese with wholegrain crackers or  crispbread
Potatoes, topped with reduced fat cheese and baked in the microwave or oven.
Corn on the cob
A boiled egg (wow, and I almost lost hope at this point)

Question: since when have desserts become acceptable snack items?

So how much have we learned so far about child nutrition from popular media and health policy providers? Not much. Still clear as mud. More googling unearths the mention of the Food Pyramid, or MyPlate for my American friends. The development of this extremely intricate logo and the accompanying website has so far cost the American Government over $2 million. According to my calculations a nasty fake-meat patty on a “plastic bread” bun topped with flavor-free lettuce and tomato and served with banana milkshake is totally MyPlate-compliant. I can’t wait for an Aussie version. MyPie, anyone?

If you are still unclear on what to pack in school lunch boxes there are also the recommendations on the number of servings. Some recommend 1/2 serve of meat or fish a day, some go for 2-3. I’ve now spent a few hours browsing popular healthy kids sites and I’m still not closer to an answer.

Out of the confusion rises one common pattern. Every child-related website/book/magazine is full of it. It’s that child nutrition is soooooo difficult. Anybody under 18 is represented as a hardcore junk food addict and they will hold your household hostage until you give them that pizza. Here is a few titles and phrases.

Feeding your children is a challenging experience

Tips for fussy eaters

Persevere, keep trying

Ingredients in disguise

Do not ban foods – they will only want them more (Is that how we feel about giving children alcohol as well?)

Constant struggle

How to hide more vegetables in a pie

Snacking challenges in the shops (C’mon, is it really that hard to survive a 2 hr shopping trip without a top-up?)

On the other hand the advice of introducing solids to babies generally includes phrases like “delicate palate”, “bland foods preferred”, “many flavors are too strong”.

How does a baby with a pure clean delicate palate turn into a toddler incapable of staying sane in a confectionary aisle? Shouldn’t a 50 year old have more addiction issues with 50 years worth of bad habits? Let’s not even mention the fact that most toddlers do not own a wallet let alone the ability to navigate a self-serve checkout. Oops, I just mentioned it.

It shouldn’t be this hard. What nutrients are essential for growth? I’m sorry but bagels and peanut butter are not essential.  However after hours of perusing popular health websites a normal and slightly befuddled parent would come to believe that perhaps they are.

They are low-carb, I swear!

Maybe we should stop assuming that our kids cannot survive without muffins, waffles and milkshakes. Stop making “acceptable” healthy substitutes whether it is low-fat/low-carb/Paleo/vegan/gluten free just to avoid a tantrum. Remember Shakespeare? A pancake under any other name…

I know we are parents but do we have to be so damn patronising? Give your children some credit. They might surprise you.

This rant was inspired by my recent research into child nutrition. Next post I promise to bring you some science on this fascinating topic. Trivia question of the day: what is the average percentage of body fat in a newborn?

Non capisco

Mediterranean diet is an oxymoron. I have met many an Italian or a Greek who will shudder at the word “diet”. But semantics aside, it is one of the most popular diet plans recommended for weight loss, diabetes and heart disease prevention. If you ask a random person on the street what the Mediterranean diet is, they will probably mention olive oil, fruits and vegetables and red wine. They might also remember cheeses, cured meats, salty preserves and rich yoghurts. But if you look at the Mediterranean diet food pyramid on the official MD website, you might get quite a shock.

Meat once a month? I think the Greeks and Italians might have missed that memo.

The story begins with Dr Ancel Keys, the father of lipophobia. In his famous Seven Countries Study which served as a basis for lipid hypothesis (and has since been thoroughly debunked by many experts) Keys brought attention to a tiny Greek island of Crete and the region of Southern Italy where people were beautiful, life expectancy long and heart disease almost non-existent. The survey of the Cretan diet revealed that they consumed little saturated fat. Aha! said Keys, because this confirmed his long-cherished hypothesis that saturated fat in the diet causes heart disease. The data from the Seven Countries Study was used to justify the anti-fat movement in America which was eventually sanctioned by the governments in the infamous McGovern Report in the 1977*. And we have been healthy and free of  heart disease and diabetes ever after.

Well, not quite.

 *For detailed description of the birth of the lipid hypothesis please read Gary Taubes’s ground-breaking article “Soft science of dietary fat” or, if you are brave enough, his impressive tome “GCBC”.

While the anti-fat coalition kept inventing new food substances like cardboard-tasting breakfast cereals and low-fat Snickers bars, the Mediterranean connection went unexplored for some time. It was revived in 1994 with the Lyon Diet Heart study. Heart attacks patients who followed the MD were had their risk of dying reduced as well as their risk of another heart attack, compared to patients on a usual “prudent” diet. It was very impressive, although I have a few issues with the study itself which I will address another time. After many studies trying to pinpoint the elusive magic ingredient behind the results (and you know what I think about magic ingredients), after resveratrol in red wine and antioxidants in olive oil, the vague consensus was finally reached: the protective power of the MD results from replacing saturated fats with polyunsaturated and monounsaturated ones.

This is the story so far. Let’s leave the biochemistry for later because I would like to start in the beginning.

The problem with the initial premise of the MD is that it is based on an observation. I have pretty awesome observational skills myself so here are some of my observations.

1. Anyone who has been to any of the 21 countries on the shore of the Mediterranean sea knows that there is no one Mediterranean diet. There is more in common between American and Australian diet, than between French and Greek.

2. While it is true that olive oil is used in Italy, Greece and Crete, the French preferentially use lard and butter, enjoying (wouldn’t you?) one of the highest saturated fat intake levels in the world. They also have the second lowest incidence of heart disease after Japan.

3. While fish is a popular part of the menu on the coast, salmon (the number one fish on any dieter’s menu) is not even native to the Mediterranean sea.

4. Wholegrains do not traditionally provide the bulk of the carbohydrate requirements on this diet.

Here is a description of Cretan agriculture:

The cultivation of the olive tree  is very important in Crete and excellent virgin olive oil is produced here. Other important products include oranges, grapes and vegetables from greenhouses. Honey, cheese and herbs are of excellent quality also. Finally, big numbers of sheep and goats are raised in Crete.

From Wikipedia:

As in many regions of Greece, viticulture and olive groves are significant; oranges and citrons are also cultivated. Until recently there were restrictions on the import of bananas to Greece, therefore bananas were grown on the island, predominantly in greenhouses. Dairy products are important to the local economy and there are a number of speciality cheeses such as mizithra, anthotyros, and kefalotyri.

And another one:

Another occupation for quite a few Cretans is fishing. Although the quantity of fish in Crete is limited the quality is generally very good.

Somehow I don’t see a lot of wholegrains. In case you think that they might be importing it, here is the link with the top 43 wheat importers in the world. Greece (and Crete) are not on the list. In case you are wondering, the US is at number 10.

4. High polyunsaturated/low saturated fat intake doesn’t stop Israel from having high prevalence of heart attacks and diabetes (so called Israeli paradox).

5. Italy, the Mediterranean country famous for it breads, pasta and cereals, also enjoys a dubious honour of having one of the highest rates of celiac disease in the world, closely following Ireland.

6. Fast forward to 50 years later and countries like Italy still enjoy their olive oil, fruits and vegetables, red wine and sourdough. In addition they also have higher activity levels than Australians, higher vitamin D levels (extra cardioprotection), lower stress levels and stronger family ties. All factors  which are supposed to ensure long and healthy life.

Here is a kicker.

Their life expectancy is now the same as for Australians: 79 for men and 84 for women.

OK, maybe they die at the same time, but maybe we have better treatments for infectious disease and less accidents? Actually, according to the WHO mortality figures, more Italians die of non-communicable diseases than Australians. Non-communicable diseases are the chronic diseases which kill you slowly: diabetes, cancer, heart disease.

Here is a mortality chart for Italy. (The picture quality is not great but you can follow the link above and select your country of interest in NCD profile)

Proportional mortality in males. Italy

Here is a mortality chart for Australia.

Proportional mortality in males. Australia

Yes, Europeans sure do smoke a lot. But their smoking rates have actually dropped in the last 50 years. So I doubt that it would explain their not-so-great performance in the health stakes. Could it…possibly…be…the increasing consumption of Western-style low-fat industrial garbage together with flour and sugar? No, of course not, it must be the fat.

As with any diet of any nation on Earth, there have to be protective factors and harmful factors. When you look at the Mediterranean factors how do you know which is which? Imagine a world where smoking is considered good for your health and vegetables are considered evil. If you then apply this reasoning to the Mediterranean lifestyle, it still works! All these vegetables are putting them at risk for a massive heart attack, thank goodness they smoke. Have you been naughty and had a cauliflower binge? Don’t forget to light up your Marlboros.

To demonstrate a perfect example of this backwards thinking, here is the American Heart Association view on the MD.

Mediterranean-style diets are often close to our dietary  recommendations, but they don’t follow them exactly. In general, the  diets of Mediterranean peoples contain a relatively high percentage of  calories from fat. This is thought to contribute to the increasing  obesity in these countries, which is becoming a concern.

So the traditional diets of the Mediterranean were higher in fat than in the US, the people in the region were slimmer than in the US, but their growing obesity is caused by their levels of dietary fat?

What happens when you combine the lipid hypothesis with a diet from a few carefully selected locations with cherry-picked ingredients?