Chocolate cake-cheeseburger diet: Coping with conflicting information
Survey shows consumers are confused
Margarine is wonderful. No, wait. Margarine is bad for you. Butter is better. Red wine helps your heart. But wait, it might damage your liver. Red meat? Eggs? Coffee? Tea? The Atkins diet? Good for you? Bad for you? Who knows? Let’s just give up and eat chocolate cake and triple cheeseburgers and be happy. Everybody knows stress shortens your life anyway. That’s an attitude that confused Americans present in the face of new research, which may, or may not, be in conflict with earlier research.
At the heart of the problem is a sound-bite-addicted society that tosses out new research results like chocolate coins at Mardi Gras — with little context or background, say experts watching American attitudes toward nutrition advice. "The more negative and confused people feel about dietary recommendations, the more likely they are to eat a fat-laden diet that skimps on fruits and vegetables," says Ruth Patterson, PhD, RD, lead author of a study from the Fred Hutchinson Cancer Research Center in Seattle.1
The study’s results show patients who are attempting to lose weight are confused, frustrated, and sometimes angry at what they perceive as conflicting messages, leading Patterson to coin a term: nutrition backlash. While Patterson’s study did not show a strong backlash, it was enough to arouse interest, she says.
Coupled with Discovery Health Channel’s recent national poll of consumers and health care professionals on obesity, the study shows Americans are increasingly in the dark about how to handle their weight problems. "It is essential that we, as health care professionals, stop at this juncture, take a deep breath, and start all over to re-educate our patients and ourselves about nutrition," says Andrea Pennington, MD, medical director of Discovery Health Channel in Bethesda, MD.
Pennington is among the first to admit that the popular press is prone to taking a brief look at a new study and "running with it without putting it into context." What’s more, patients often will come to the physician’s office clutching a handful of printouts of studies they have found on the Internet — studies they believe prove a particular diet aid or diet plan works — not even realizing that the web sites they are searching often are almost purely advertising.
"Margarine was one of the biggest causes of confusion," says Patterson. "I have friends who tell me they felt betrayed by the medical community and the food industry when they were told butter was bad, so they ate margarine unhappily for 10 years only to find out that margarine raises cholesterol, too."
Help them put it in context
"Help your patients put these things in context," says Wahida Karmally, MS, RD, director of nutrition at the Irving Center for Clinical Research at Columbia Presbyterian Medical Center in New York City. One study is not a final prescription, she says. "I think we need to help people understand that nutrition is an evolutionary science," says Karmally, who is also a spokeswoman for the Chicago-based American Dietetic Association. "It is a continuously changing body of information, and each new study we get adds to what we know."
Using the margarine-butter example — 10 years ago, health professionals did not know about the cholesterol-raising effect of the trans fatty acids found in margarine, she says. However, people shouldn’t jump back to the Dark Ages by slathering butter half an inch thick on bread because what was known a decade ago about the cholesterol-raising effects of butter and animal fats still holds true.
"The idea that margarine may be bad doesn’t mean butter is better," Karmally explains. "We should convey to our patients that this is exciting, not that it is confusing, because we are learning so much more."
Calories do count
Patterson’s epidemiological study, based on a random telephone survey of 1,751 residents of Washington state, showed 70% of those who answered think Americans are obsessed with the fat in their diet, and the same percentage thought the government should not tell people what to eat. Furthermore, those who Patterson classified in the nutrition backlash category were more likely to consume more fat. Frustrated folks had a fat-related diet habit score of 2.11 vs. a score of 1.73 among those less frustrated with their dietary messages, reflecting approximately 4% more fat consumption in terms of total calories for those who say they "don’t get it." Individuals in the "high-backlash" category ate only 2.72 servings of fruits and vegetables per day, compared with 3.35 servings for those in the "low-backlash" category, she adds.
"Americans are looking for the magic bullet against fat," says Patterson. "I am convinced there is no single answer, but as long as we’re looking in just one place, we’ll always be disappointed." No matter what the Atkins diet or any of the dozens of other pop diets promote, Patterson says that calorie counting is at the heart of weight loss. "With 55% of Americans overweight, it is obvious we are eating too many calories and not moving enough," she says.
Pennington weighs in on the issue with some similar thoughts. Discovery’s survey of 750 consumers as well as 78 doctors, 53 nurses, and 41 nutritionists and dietitians showed a vast gulf between the attitudes of health care professionals toward weight loss and the attitudes of their patients. The Discovery Health Channel study, developed with assistance from the Atlanta-based Centers for Disease Control and Prevention’s Division of Nutrition and Physical Activity, showed that 41% of all Americans believe excess weight is due to factors outside a person’s control and 67% believe that those who are clinically obese have no control over their weight.
In direct conflict with public opinion, doctors, nurses, and dietary health professionals said in the survey that most adults can maintain a healthy weight if they are motivated and exercise self- control. Only 7% of doctors, 10% of nurses, and 15% of dietary health professionals think that weight is due to factors beyond a patient’s control. The conflict runs even more deeply than more health care professionals suspect, the study shows:
— Americans believe the kind of food a person eats is more important than the amount of food eaten. Health professionals agreed that the kind of food a person eats is important, but they also think the number of calories eaten plays a role in weight loss and weight maintenance.
— 37% of Americans cite reasons why people gain weight that are beyond a person’s control:
- depression (11%);
- genetics (10%);
- metabolism (6%);
- personal life problems (6%);
- medical problems (4%).
— Doctors cite motivation (19%) as the most important barrier to treating overweight and obese patients.
— Other than "liking to eat," (18%), the No. 1 factor Americans cite for their difficulties in losing weight is self-control. Americans recognize how hard it is to lose weight far more than the medical community.
— Few, if any, Americans cite weight-loss diets as effective in helping them manage their weight on a long-term basis, and many believe they do not work in helping them lose weight. Health care professionals offer an answer for this: Weight-loss diets are effective in helping patients lose weight but are not effective in helping them keep it off. While science may be on the side of the health care professionals, in reality, patients remain unconvinced.
What can we do?
For starters, health care professionals need to change tactics, says Pennington. "When I am face to face with patients with weight issues, I show them scientific evidence of the health hazards of excess weight. I tell them this is science; it’s not just my opinion."
"The should’ word is a turnoff. People want the information so they can make choices themselves," Patterson adds. Be calm, she advises. "They may not like hearing this, but there is no evil food, and there is no perfect food. There is no magic pill, and there is no single answer to their problem."
The basic message hasn’t changed, says Patterson. "Look for different ways to say it: A diet high in fruits and vegetables, low in fat, and with a wide variety of foods will help you lose weight and keep you healthy." She admits, "It’s not a very sexy message to sell. The truth is that people need to put more priority on their food intake."
Walking down the street eating a hot dog, chowing down on a Big Mac while driving the car, or wolfing a pizza while watching the big game are sure signs that food is not a big priority in the lives of most Americans. "Urge your patients to invest in themselves. Buy good, wholesome, high-quality food. Take the time to prepare it, and sit down and enjoy it," she says.
"The only way I get their attention is to compare their eating habits to their sex habits. I can be sure they are listening," Patterson laughs. "I ask them, would they have sex in the car? In front of the TV? Walking down the street? Food is probably even more important than sex, so I suggest they give it the attention it is due."
Most people can find the resources to buy higher quality food, but they simply don’t link food intake with long-term effects on health, say all three health care professionals. Health care professionals need more education on nutrition-related issues so they can better convey these messages to their patients, suggests Pennington. "We also need to better appreciate the psychological dimensions of obesity and the poor self-image and depression that often result from it, not to speak of the physical health concerns," she says.
Help your patients bite off what they can chew, she suggests. "Five servings of fruits and vegetables a day can be overwhelming. It’s got to be something simple they can do. Get them to add one more fruit or vegetable a day, and you’ve gotten somewhere."
Adding to that thought, Karmally suggests: "Choose the fruits and vegetables and other foods you like, and build on that. Learn to eat like an adult should eat. We know kids usually don’t like things like spinach and green vegetables. Ask them to work to acquire those tastes slowly."
An approach to childhood obesity
The clean plate club is a prime example of poor parental attitudes about eating that can persist into adulthood, says Pennington. It is simply a way of encouraging overeating. Conversely, parents who condone finicky eating habits or even encourage kids to choose what they will eat are setting their children up for a lifetime of weight-control problems too, says Pennington. Fully three-quarters of all parents cook separate meals to suit their childrens’ food preferences. "Ninety percent of doctors blame childhood obesity on poor parenting," she says.
Parents need to start promoting healthy eating habits from day one, she says. That means all children, from newborns through teen-agers, should have limitations put on their food choices. "I was appalled one day to be in McDonald’s and see a baby being fed French fries," she says. "Fat and salt taste good; they activate the neurons that stimulate the pleasure centers of the brain. That’s why we eat so much of that stuff. And it’s why we shouldn’t cultivate those tastes in the very young."
Limit portions, limit snacks, don’t use snacks as a reward, and encourage family play (translation: exercise) so that exercise is a normal part of life. "I hear parents all the time telling me they have no time to prepare healthful meals, that their lives are so hectic that they wind up choosing fast food more often than they would like. I tell them to look for small steps to make big changes. When they’re cooking on the weekend, make extra and freeze it for easy and quick meals. If there’s a will, there’s always a way," says Pennington.
Reference
1. Patterson RE, Satla JA, Kristal AR. Is there consumer backlash against the diet and health message? J Am Diet Assn 2001; 101:37-41.
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