Sunday, May 15, 2016

On Moderation

Moderation is a common buzzword applied to many conversations on diet and to dietary advice you’ll find, particularly in the media.  Moderation is promoted as a guide to healthy and sustainable eating.

A lot of dietary concepts are poorly or inconsistently defined.  What is a healthy diet?  You can expect each person to come up with something slightly different based on their own beliefs.  What is low carb?  Definitions range from ≤ 50g/day to ≤ 40% of total calories.  Is conventional dietary advice promoting a low fat diet at 20-35%, or is a true low fat diet one where fat provides ≤ 20% of total calories? (see High This, Low That for my proposed definitions)

The dictionary definition of moderation is quite clear (‘the avoidance of excess or extremes, especially in one's behaviour or political opinions’), but moderation is perhaps the most poorly and inconsistently defined dietary concept, and as a result, left to individual interpretation

People selling you the concept of moderation have it easy.  They can sell you something that sounds easy and they themselves don’t need to do the work to come up with specifics, do research to justify their recommendations or be accountable for them

More insidiously, the widespread promotion of moderation, particularly by dietetic groups with conflicts of interest, helps the food industry who can promote the consumption of their food products in moderation or as part of a balanced diet.  The goal of the food industry is to sell as much of their product as possible, leading to the development of hyperpalatable and highly rewarding foods, and it can be challenging to make moderation work when such food is ubiquitous in the modern food environment.  Also, the ‘as part of a balanced diet’ implies that the food product has some role or function in a balanced diet, rather than being the discretionary extra that it so often is

In the modern food environment most people need to be restrictive with what they eat to some extent in order to maintain leanness and health.  The conventional way to do this is by restricting calories, but the leptin resistance of obesity and highly rewarding foods makes this extremely difficult to do in the long term, with hunger being the Achilles heel of calorie restricted diets

The alternative is to restrict the types of food.  This idea is attacked by people who argue that there are no ‘bad’ foods (seriously…) and that restricting the types of foods you eat is orthorexic behaviour.  However, the behaviour of restrictive eating itself isn’t sufficient to cause orthorexia, much like cleaning and organising stuff doesn’t cause OCD, and most importantly, like calorie restriction doesn’t cause anorexia.  Orthorexia, like all mental health issues, depends on the thoughts and behaviours impairing function and/or causing suffering, and conscientious or restrictive eating do not necessarily mean that orthorexia is present

In addition, when it comes to reducing the intake of unhealthy food (or other behaviours), there are two main strategies to do so: eating a little bit of unhealthy food some of the time (moderation); and avoiding the unhealthy food altogether (abstinence).  The conventional narrative is generally that moderation is preferable, as avoiding the food will almost inevitably lead to a future binge and the typical yo-yo dieting.  But it’s likely that people are generally better suited to one of these two strategies (moderation and abstinence) and that one of these strategies isn’t an effective recommendation for everyone.  I was introduced to this in ‘Better Than Before’ which had a chapter on ‘moderators’ and ‘abstainers’ as personality types relevant for habit formation

I’m pretty sure I’m very much an abstainer.  For me, there’s generally no such thing as one piece of chocolate or one YouTube video, and a resolution to eat less chocolate or watch less YouTube videos would be most easily met by not buying any chocolate for myself and not opening YouTube at all until my work for the day is done.  For me, the moderation approach would be more useful for training willpower than being the easiest way to achieve my goals directly

What’s works as moderation for one person may not be enough for another, and may be unnecessarily restrictive for another still.  When it comes to diet try something to some extent.  If that works, great!  If it doesn’t, then consider trying it more vigorously – tailor your commitment to a dietary approach based on the degree of results you’re looking for.  If that still isn’t working after an honest attempt, then consider other dietary approaches, other lifestyle approaches (it might not be a diet issue), and also whether your goals are realistic

Moderation and abstinence are just strategies that you can play around with and figure out what works for you.  You may also find moderation to be better strategy for one thing and abstinence better for something else

Orthorexia, OCD and Feelings of Lack of Control

In an earlier post, I mentioned that there’s a relationship between orthorexia and obsessive compulsive disorder (OCD).  The diagnostic criteria reads a lot like a description of OCD, but is specifically about food, health, body image, etc.  Unfortunately, there doesn’t seem to be much on this link besides that review paper and the diagnostic criteria as the research on orthorexia is in its infancy and mostly being prevalence studies

So the cases of orthorexia haven’t really been discussed much.  It’s easy to build a narrative that restrictive diets lead to orthorexia.  In some cases I agree, but this doesn’t account for why people go on restrictive diets in the first place

Again, the research is limited and there are issues with the ORTO-15, so I don’t want to use associations in the prevalence studies here, but there are a few case studies in the literature and the media.  These cases are likely to be more extreme than the ‘average’ case of orthorexia and so may not be representative, but most developed orthorexia in response to health issues (acne) [1] (tic infection) [2] (constipation) [3] (digestive issues) [4], and there’s a case study of a woman who developed orthorexia as an early symptom of schizophrenia [5]

This obviously isn’t a justification for orthorexia, and I’m not saying their orthorexia is a preferable alternative to their initial health issue.  These people weren’t in good health to begin with, but their extreme orthorexia made them much worse.  Though this can be an explanation as to what triggered their orthorexia*

So how may health issues be a trigger?  OCD can be caused by the sufferer feeling a lack of control in a specific thing, which manifests as an obsession.  The compulsions are then an attempt to re-establish control.  Similarly, someone with orthorexia may feel a lack of control regarding their health.  They then develop food obsessions based on what they’ve read/heard or patterns in their own health, and the restrictive eating is an attempt to re-establish control.  The compulsions in OCD and the restrictive eating in orthorexia are coping strategies, but just not very productive ones.  Because as we’ve seen in the 4 case reports, the restrictive eating can cause psychological distress, doesn’t necessarily address the initial health issue and can create new health issues

I think to some extent it is human nature to develop irrational beliefs and compulsive behaviours to try and feel in control of things that we are at the mercy of and don’t understand.  Humans have been doing this for a long time, and I noticed this developing with a previous issue I had, so no judgement or shaming from me

Whatever the prevalence of orthorexia is, I suspect that far more people feel a lack of control over their weight or health and have exaggerated fears on food and disease, but just don’t consistently act on them.  A major problem here is the high prevalence of chronic diseases in the community, the general failure of modern medicine to adequately treat these diseases, and our society’s narrative on health, aging and chronic disease – all of which leads to feelings of a lack of control.  In response to this the underlying philosophy of Ancestral Health/Paleo** can be very empowering while also actually being quite effective and ends the tracking of calories or macros.  The trick here is to make the message effective without including the fear mongering that can lead to orthorexia*** and giving people more than one strategy for influencing their diet (see next post).  This is why Paleo and its variants has helped some but harmed others (see Orthorexia in the Paleo/Primal Community)

* I suspect a health issue will be a more reliable trigger if it is difficult to treat, is visible (skin and weight) and have fairly regular symptoms that could provide feedback (skin and digestion particularly).  Not everyone who has a health issue will develop orthorexia (obviously), as it also depends on underlying personality characteristics that may include obsessiveness, black and white thinking and catastrophising

** The very low prevalence of chronic disease in hunter-gatherers and traditional cultures, the evolutionary argument against chronic disease and that ‘humans are not broken by default

*** I think the underlying philosophy should protect against this, but many diet books have the narrative of ‘avoid these foods that are killing you and eat these superfoods that will save you’ (note the black and white thinking and catastrophising)

Saturday, April 30, 2016

Self Assessment with the ORTO-15

In the previous post I mentioned how there are issues with the validity of the standard questionnaire (the ORTO-15) to diagnose orthorexia (or health fanaticism) in those orthorexia prevalence studies.  So I went through the ORTO-15 and surveyed myself, and this made me more strongly agree with those concerns of validity.  Before I go through the ORTO-15, just note that I would answer no to all of Dunn & Bratman’s proposed diagnostic criteria (see previous post)

 As a general note these questions are a bit ambiguous at times.  Besides wondering what ‘often’ and ‘sometimes’ should be operationalised to mean, questions along the line of ‘Do you think X’ (questions 9, 10, 11, 12, 14) could be interpreted in a few ways.  Just to use question 9 as an example, it could be interpreted to mean either: ‘how often do you do you think your mood affects your eating behaviour’; or ‘do you think your mood often affects your eating behaviour’.  In addition, the ‘your’ in questions like question 9 could be referring to yourself or to people generally, though I suspect the former.  I might be overthinking this, but I think it’s plausible that if you gave questions like question 9 to a bunch of people you would get 4 different interpretations of the question from the sample.  So I’ll answer that type of question two different ways and assume ‘your’ means yourself

Lower scores are more indicative of orthorexic tendencies

1.      When eating, do you pay attention to the calories of the food?
Sometimes (3).  It can sometimes be a good idea to know roughly how many calories are in something and that when considering a dessert for example, 100g of cake contains a lot more calories than 100g of fruit and is proportionally less satiating.  Most of what I eat doesn’t have a calorie label and that doesn’t concern me

2.      When you go in a food shop do you feel confused?
Never (1).  When I go into a food shop I know what I want to buy and don’t spend much time doing so (10-15 minutes for a weekly shop).  I think you could be confused if you had an introductory level of nutritional knowledge that was strongly influenced by the contradictory messages in the media, and then debating between various processed foods (should I buy the low fat muffin or the gluten free brownie, etc).

3.      In the last 3 months, did the thought of food worry you?
Never (4).  I don’t think it should unless you had something like IBS, IBD or coeliac disease, which would be quite understandable

4.      Are your eating choices conditioned by your worry about your health status?
Never (4).  I would describe myself as being invested in my health status, but not worried about it.  With questions like this and question 3 you can see how easy it could be for someone trying to do something about a health condition they have to be labelled as orthorexic

5.      Is the taste of food more important than the quality when you evaluate food?
Sometimes-often (2.5).  The food I eat is simple, but tastes nice.  But I don’t regularly eat junk food even though it tastes better

6.      Are you willing to spend more money to have healthier food?
Sometimes (3).  Healthy food doesn’t have to be that expensive and I limit expenses by generally only purchasing fruit and vegetables at ≤ $4/kg, and meat at ≤ $10/kg.  Berries might be the healthiest fruit, but at $20+/kg it’s hard to justify the need for them.  That being said, meat, fruit and vegetables are definitely more expensive per calorie than things like bread, pasta or rice.  Perhaps I would answer ‘often’ if I had a higher income

7.      Does the thought about food worry you for more than three hours a day?
Never (4).  That’s a very long time to worry about food and could be a sufficient diagnostic criterion in itself

8.      Do you allow yourself any eating transgressions?
Sometimes (2).  Unhealthy food doesn’t makes up a fairly small part of my diet, I eat a small amount of ice cream fairly regularly, some chocolate/etc when it’s gifted to me and eat out or buy lunch rarely (only without someone else and mainly because it’s much more expensive than making your own).  But ‘eating transgressions’?!  That’s pretty strong language and certainly not the kind of way I would describe eating unhealthy food.  Apparently only ‘sometimes’ is pretty orthorexic though

9.      Do you think your mood affects your eating behavior?
Interpretation 1: how often do you do you think your mood affects your eating behaviour.  Sometimes (2).  I rarely think about this probably because I don’t engage in very obvious emotional eating
Interpretation 2: do you think your mood often affects your eating behaviour.  Always (4).  Because mood always has some effect, just to varying degrees (note: I don’t think we have free will)

10.  Do you think that the conviction to eat only healthy food increases self-esteem?
Interpretation 1: how often do you think that the conviction to eat only healthy food increases self-esteem?  Sometimes (3).  I very rarely think about this
Interpretation 2: do you think that the conviction to eat only healthy food often increases self-esteem?  If someone resolves to eat healthfully and then successfully does so, that can increase self-esteem in a very healthy way, just like resolving to and then successfully completing any other activity (Often (2)).  It won’t increase self-esteem much for me though because my eating habits are quite routine.  But conviction on its own without action wouldn’t increase self-esteem for me though because I haven’t achieved/done anything (Never (4)), but may increase self-esteem in other people (Sometimes (3))

11.  Do you think that eating healthy food changes your life-style (frequency of eating out, friends, …)?
Interpretation 1: how often do you think that that eating healthy food changes your life-style (frequency of eating out, friends, …)?  Sometimes (3).  I very rarely think about this
Interpretation 2: do you think that eating healthy food often changes your life-style (frequency of eating out, friends, …)?  Sometimes (3).  I’m comfortable eating pretty much whatever in the odd social situation.  Paleo was a gateway for my interest in chronic disease research, the blog and the people I follow on twitter, but if I changed the way I ate, without changing what I think, then I don’t expect the other stuff would change

12.  Do you think that consuming healthy food may improve your appearance?
Interpretation 1: how often do you think that consuming healthy food may improve your appearance?  Sometimes (3).  I don’t think about this very often
Interpretation 2: do you think that consuming healthy food may often improve your appearance?  Sometimes (3).  For the most part the foods I eat have a unnoticeable effect on my appearance (as something that changes slowly anyway), but could easily have subtle long term effects on aging.  I find some foods (wheat, chocolate) can sometimes give me a little bit of acne

13.  Do you feel guilty when transgressing?
Never (2).  Again, such strong language with ‘guilty’ and ‘transgressing’.  I have never felt guilty when eating unhealthy food.  I have sometimes regretted those decisions, but eating unhealthy food isn’t something that’s morally wrong to feel guilty over.  But apparently my response is pretty orthorexic though

14.  Do you think that on the market there is also unhealthy food?
Often (2).  Of course there is unhealthy food in the market, most of it isn’t healthy and that shouldn’t be a controversial statement

15.  At present, are you alone when having meals?
Often (2).  Simply because I’m currently living by myself

I scored 40.5 with interpretation 1 and 42.5 with interpretation 2.  Most studies have used a score of less than 40 as the cut-off point that indicates orthorexic behaviours, so the ORTO-15 would suggest I have borderline orthorexia or are at risk of orthorexia, but you can judge for yourself on whether that is the case

I hope you can now see quite clearly how those prevalence studies were able to find such surprisingly high prevalence rates for orthorexia.  Another issue with the ORTO-15 is that the questions and responses (‘often’ and ‘sometimes’) can be interpreted in many ways and that some questions don’t necessarily do a good job of assessing orthorexia or lack thereof in some circumstances, and these other issues may explain how associations between orthorexia and other factors has been inconsistent or absent in the literature

Summary of the Research on Orthorexia

At the time of writing this post there are 49 papers on PubMed on orthorexia.  Needless to say, the research is in its infancy, but that doesn’t mean it isn’t a legitimate condition.  Most of the studies on orthorexia are looking at the prevalence of orthorexia in a specific population (mostly in university students, but also dieticians, people with other eating disorders, etc) and/or are looking at associations between various personality characteristics such as perfectionism with orthorexia.  There are also several pretty extreme case studies in the literature

The Othorexia Prevalence Studies

The prevalence studies used a questionnaire called the ORTO-15 (or a derivative of it) and have reported a very wide range in the prevalence of orthorexia (between 6 to 88.7%) that is generally very high (~30-80%) [1] [2].  The following table comes from [1]

Prevalence rate (%)
Donini et al. (2005)
Bosi et al. (2007)
Aksoydan and Camci (2009)
Fidan, Ertekin, Işikay, and Kirpinar (2010)
Ramacciotti et al. (2011)
Alvarenga et al. (2012)
Segura-García et al. (2012)
Men: 28 Women: 30
de Souza and Rodrigues (2014)
Varga et al. (2014)
Valera, Ruiz, Valdespino, and Visioli (2014)
Asil and Sürücüoğlu (2015)
Brytek-Matera, Donini, Krupa, Poggiogalle, and Hay (2015)
Men: 43.2 Women: 68.6
Gubiec et al. (2015)
Jerez et al. (2015)
Missbach et al. (2015)
Stochel et al. (2015)
Study 1: 53.7 Study 2: 52.6
Segura-Garcia et al. (2015)
Clinical: 58 Control: 6

If the high and variable prevalence rates sounds weird, that’s probably because it is.  Several studies have brought up issues with the ORTO-15 including:

·         That “it is counterintuitive to believe that a phenomenon of restricted eating that is not well understood has point prevalence rates found to be as high as 88.7 %, with repeated findings of 30–80 %” [2]
·         That “in this study, it is remarkable that 80 % of the sample endorse that they do not restrict the type of food that they consume, yet the ORTO-15 identifies over 70 % of the sample suffering from ON” [2]
·         That the ORTO-15 doesn’t do well at distinguishing healthy eating from disordered eating very well [2] [3] [4]
·         Issues with the questions and scoring [3]
·         The inconsistent associations between ORTO-15 scores with age, education, BMI, smoking, alcohol, and sex [4]

Orthorexia and OCD

In contrast to the ORTO-15 (which I’ll show you in the next post), in a recent review Dunn & Bratman [1] proposed some diagnostic criteria for orthorexia

Criterion A: Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue as a result of dietary choices, but this is not the primary goal. As evidenced by the following:

1.       Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices believed by the individual to promote optimum health.
2.       Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.
3.       Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy eating.

Criterion B: The compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:

1.       Malnutrition, severe weight loss or other medical complications from restricted diet.
2.       Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviors about healthy diet.
3.       Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior.

This is very similar to some other proposed diagnostic criteria by Moroze et al [5]:

Both sets of diagnostic criteria emphasise the two factors that for something to be disordered eating (as opposed to conscientious eating) it needs to cause suffering and impair function (the two key factors that really define whether something is a mental health issue or not).  They also emphasise that orthorexia is a very similar condition to obsessive compulsive disorder.  Something that is discussed well in the following review (and something I’m planning to write about later) [4]

* Orthorexia and anorexia are distinguished by orthorexia being about food quality for health and anorexia being about food quantity for weight loss.  It’s a simple story, but what about the two other combinations: an obsession on food quality for weight loss, and on food quantity for health.  The latter two could both fall into the category of orthorexia, and I can think of some examples for each of them

Monday, April 25, 2016

Ramsden et al Recovers Data from the Minnesota Coronary Survey

Ramsden et al have previously written a meta-analysis [1] and a review [2] critical of the mainstream view that replacing SFA with mainly n-6 PUFA would reduce the risk of coronary heart disease (as well as other research on n-6 PUFA).  They later recovered some missing data from the Sydney Diet Heart Study (SDHS) [3] and more recently did the same for the Minnesota Coronary Survey (MCS) (they call it the Minnesota Coronary Experiment (MCE)) [4].  SDHS and MCS are both unfavourable trials for the diet heart hypothesis [5].  This paper was widely publicised in the media because those guys love controversy

Ramsden et al described MCS as “perhaps the most rigorously executed dietary trial of cholesterol lowering by replacement of saturated fat with vegetable oil rich in linoleic acid. The MCE is the only such randomized controlled trial to complete postmortem assessment of coronary, aortic, and cerebrovascular atherosclerosis grade and infarct status and the only one to test the clinical effects of increasing linoleic acid in large prespecified subgroups of women and older adults.” [4]

It’s this autopsy and subgroup data that Ramsden et al’s paper has recovered and is largely publishing here (see table 1)

It’s previously been reported that compared to the control group, total mortality was equal in men (RR = 0.99) and slightly higher in women (RR = 1.16) (average RR = 1.08).  The newly recovered data show this slight increase in mortality to be due to people aged at least 65.  What’s interesting about the mortality figures is that the separation in the ≥ 65 age group starts to begin at around 600 days (figure 5)

This is similar to observation Chris Masterjohn made about the Los Angeles Veterans Administration Trial (LAVAT), that cancer mortality began to be higher in the experimental group at 2 years and non-CVD mortality at 4-7 years [6].  Forget about the defence against this paper that the trial was too short to demonstrate the benefits of n-6 PUFA – cholesterol levels change within a week or two and so if that’s the primary mechanism then the benefits should start right away.  On the other hand, if the harms of excess n-6 PUFA are somewhat mediated by changes in tissue lipid composition, then you would expect the harms of excess n-6 PUFA to take a while to develop

This is followed by looking at the relationship between changes in cholesterol during the trial with total mortality (figure 6 and table 4).  They found that a reduction in cholesterol during the trial was associated with higher mortality, in both groups.  This is really an observational study like result within an RCT and can’t be used to establish causality as you can’t determine whether diseases and their treatment lowers cholesterol or whether lowering cholesterol makes one more susceptible to other diseases.  It is consistent with reviews of observational studies that found the relationship between total-C and total mortality to be a U-shaped curve [7], and another that found among older people this U-shaped curve was shifted to the right (lowest mortality at higher total-C) or an inverse relationship [8]

The autopsies data found that: “41% (31/76) of participants in the intervention group had at least one myocardial infarct, whereas only 22% (16/73) of participants in the control group did (incidence rate ratio 1.90, 95% confidence interval 1.01 to 3.72; P=0.035). Also, participants in the intervention group did not have less coronary atherosclerosis or aortic atherosclerosis (table 5).”  However, as Ramsden, et al point out “These findings should be interpreted with caution because of partial recovery of autopsy files. There was no association between serum cholesterol and myocardial infarcts, coronary atherosclerosis, or aortic atherosclerosis in covariate adjusted models (table G in appendix)”.

Ramsden et al’s paper isn’t earthshattering but is certainly nice to have.  Reading this study brought to the front of mind a few things I’m aware of but haven’t emphasised much yet:

·         The diets used in MCS were based on diets in the National Diet Heart Study.  The experimental diet in MCS was based on diet BC and the control diet In MCS was based on diet D.  NDHS aimed for most of the fat to come from specially formulated food products (filled meats, dairy, etc).  The added fat in the filled foods came from vegetable oils for the experimental diets such as BC and “either animal fat or hydrogenated shortening” for diet D.  There’s more detail on the diets in [4].  When you consider this, even a neutral result in the trial would be unfavourable for the diet heart hypothesis

·         MCS finished in 1973 but the manuscript was published in 1989 – 16 years later.  There are three abstracts in a supplement of Circulation in 1975 as the trial was also discussed in an American Heart Association conference around that time*.  But still this could be argued to be borderline publication bias**.  I also doubt that the publication of MCS would have changed much in the first dietary guidelines.  Even after MCS and DART (a neutral trial) were published people who support the diet heart hypothesis still find ways to do so and to rationalise away unfavourable results (you only need to look at the rapid responses and the media for this)

·         On a somewhat related note, the favourable diet heart trials were the ones with the most publications (ODHS (4 + monograph), LAVAT (12 + monograph), FMHS (6), HDAT (4) and STARS (9)), while the unfavourable trials had the least (RCOT (1), SDHS (2) and MCS (1))

* The 3 abstracts are difficult/impossible to find online but I was able to find them at Melbourne University’s library.  They give very little additional information unless you’re totally obsessive, because they report a different number of participants (Abstracts 9449, Manuscript 9057, Ramsden et al 9570) and the number of participants who had a major CVD event (CVD M,P) whereas the manuscript reported the number of major CHD events (CHD M,E)

** Funnel plots are used in meta-analyses to look for the probability of publication bias, where an asymmetric funnel plot suggests publication bias (here are some really bad examples [9] [10]).  I noticed some asymmetry in my funnel plots of the diet heart trials for major CHD events (top left) and total CHD events (top right), but not CHD mortality (bottom left) or total mortality (bottom right).  This is limited by the small number of studies (N = 11) and may simply reflect methodological differences rather than publication bias.  But it makes you wonder

I would also recommend reading George Henderson's rapid responses and Chris Masterjohn's post