My High Calorie Intake Could Make Me Forgetful?

A Response to the Mayo Clinic's Press Release on Overeating and MCI


UPDATE! Read the response in "comments" from the primary investigator!

Yes I'm distressed!

I'm pretty worked up right now. Could be because the media is suggesting I should eat less, and I don't like it when I'm told to eat less—particularly for no good reason. And maybe it's because I take my mental function seriously, particularly living with Multiple Sclerosis, which can impact cognitive function. So best not to make unsubstantiated claims about what's gonna impact things like my memory unless it comes from good, solid science.

I'm perplexed. Could I really be the only one who sees the great irony in the opening statement of this Mayo Clinic press release stating that higher calorie intake, as self-reported by those with memory loss, ages 70-89, is associated with greater mild cognitive impairment (MCI)? Under the title Overeating May Double The Risk Of Memory Loss  the authors conclude "Cutting calories…may …prevent memory loss as we age." The study suggests that eating "too much" (more than 2,143 calories) may double the risk of memory loss.

Yes, the very people assessed to have the worse cognitive function reported the highest, sometimes extremely and unbelievably high calorie intakes. And as the press release video reveals, we're talking significant impairment (as in “Oh my, I've forgotten I was supposed to fly to New York yesterday" — oops!)

"Vell, I believe I had a couple of chickens, a pinch of shmaltz,
a few spoons of potatoes and a pint of borsht."

It's well established that self reporting dietary intake is full of errors—generally, the underweight err on the side of over-representing food intake, while the overweight do just the opposite. But self-reporting by the cognitively impaired? Is this some sort of joke, an April Fool's prank come early?

Even self-reported food intake using a validated assessment tool has its faults. (As in the Harvard study.) Being validated does not mean that the findings are real, that they reflect what was truly eaten. It merely addresses reproducibility. In this Mayo Clinic study, the only thing that was truly confirmed (as reported in the press release) is the degree of impairment, as assessed by more than one source. So we know participants are truly cognitively impaired, but we don't know with certainty how much they really ate calorically in the preceding year they were reporting on. Quite the population for accurately reporting, retrospectively, the amount they ate!

Maybe, given their MCI, they've forgotten how many portions they really consumed? Or perhaps they forgot that we typically don't report these things honestly.

The Joke is on Us

So here's my beef. The Mayo Clinic's press release, and subsequently the media outlets which picked it up, misled us. Even if my reasoning is off and all of the potential places where the science seems shabby were fully explained in the full study (which is yet to be released) there remains this problem—the media's conclusions suggest causation when at best we have an unexplained association.

The research summary states that higher calorie intake is associated with more cognitive loss (but does not necessarily cause it). So to then conclude, as most every article has, that we should be reducing our food intake, “cut out the chips” even, limiting our calories to prevent memory loss couldn't be more absurd! How unreasonable to manipulate us with these faulty one-liners, these irresponsible conclusions.

The Real Answer May Lie With BMI

The study controls for variables that might otherwise have confounded or confused the results. The researchers appropriately ensured that the finding, the increase in MCI with higher calorie intake, was not the result of such variables as diabetes, stroke, and, important to this argument, BMI. In other words, if I understand the press release and study abstract correctly, the increase in MCI associated with increased calorie intake at the highest intake levels, was not due to BMI. So BMI would not have been similarly increasing along with the cognitive impairment. Or, for that matter, with caloric intake.

So here's where I run into some difficulty. The study is stating that some, manyindividuals ages 70-89 years, are consuming > 2,000 to 6,000 calories daily, if we believe what they self-reported. And this is not linked with increasing BMI? If it isn't, that means people eating a rather extraordinary amount of food have no higher BMI than those at lower intakes. Soooo, if they are eating so much, but don't have higher BMIs, than how do we explain this?

There are several possible explanations. They could be expending more calories from exercise. Yet from the abstract, there was no mention of activity level—a major omission if we are assessing intake and making claims regarding the effects of intake without exploring output. Maybe it's exercisethat's linked with MCI, for goodness sake, as exercisers would need to be eating at higher calorie levels. “Exercise Causes Cognitive Impairment.”  Wouldn't that make for a headline!

Or, maybe there is some other medical explanation for such high intakes without resultant higher BMI. Are they malabsorbing—as in such conditions as celiac disease? This would result in nutrient deficiencies, which certainly may be responsible for cognitive losses.

Or maybe they have some thyroid condition, or cancer, not yet diagnosed, which may account for greater expenditure of calories, and may also impact cognitive function. I am no expert on memory loss—that I can say with certainty. But it appears the researchers have not done due diligence regarding their study and its conclusions.

In fairness, all the answers may be in the full research paper, yet to be published. Yes, I requested it, but was only presented with the abstract and the press release; even my questions regarding exercise were ignored.

Even referring to the higher calorie intake as “excessive” or "overeating", leaves me scratching my head—on what grounds? If you are more active than your peers at 75 years old—still playing tennis, walking regularly, golfing in your retirement years, even hiking as I've seen many a 70 and 80 year old do—wouldn't you need to be consuming more calories? Why should they be labeling this higher intake excessive, unless it is resulting in an undesirable weight increase outside of their normal range? But I didn't see this addressed in either the abstract or the press release.

And why should you care?

You, my readers, do not match the profile of the study participants in terms of age. But you are being irresponsibly told that lower calorie intake may prevent cognitive failure. And when it comes from a reputable establishment such as the Mayo Clinic, and sealed as a reality in the written word of such media outlets as the Wall Street Journal, Time Online, and others, you'll believe it.

You'll believe that higher calorie intake is detrimental—regardless of your caloric need. And then another study may arise (like the Harvard study) drawing similarly inappropriate conclusions, and you'll buy into those senseless conclusions, too. And soon you'll be so inundated with all this "science" that you'll be overwhelmed about what you can eat and what you should avoid and how much. See the problem?

What can you do? Don't be too quick to accept the written word as fact. Await a follow up study that might confirm findings. And be careful about where you get your information. Sure, reputable resources are better than sites promoting and selling something, with a financial interest in convincing you of the value of their words. But even seemingly solid institutions and individuals can draw the wrong conclusions. When in doubt, discuss such articles with those capable of shedding some light on the findings.

The unfortunate end result of early publication of scientific studies is a loss of trust. Studies that haven't yet made it for publication in peer-reviewed journals have no place in the hands of the public. Misinformation runs rampant, and as consumers of this information, we are left overwhelmed and confused. And it's a bad state of things when we can't trust science.

Diet Solution to Weight Gain Epidemic Revealed!

An RD’s lessons from the Harvard Study

Thanks to Right Angle Tutors for use of this photo

Harvard researchers just discovered the cure to the so-called obesity epidemic. Or so you may think from their press release June 22, 2011 and from the media blitz that followed Effect of Lifestyle On Weight Gain, published in the NEJM. Powerful statements linking specific foods and food categories with resulting weight change emerged. And any progress we had made as a society toward a balanced approach to eating, to a move away from rigid food rules, crazy diets, and food paranoia was destroyed. They concluded the following:

• There are ‘good’ foods and there are ‘bad’ foods 
• Focusing on specific foods to avoid versus counting total calories is the way to consume less 
• Changing carbohydrate type is the answer for weight control, by eating less sugars and other sweets
• Fruits, vegetables, whole grains, nuts and yogurt prevent long term weight gain



Do the fruit and nuts get to count as a fruit serving in my chocolate?

• Potato chips, French fries, boiled, baked, mashed potato, sweetened soda, and meats are associated with the obesity epidemic

The study results and conclusions were further echoed throughout the media. Even Jane Brody, from the NY Times, wrote an article entitled “Still Counting Calories? Your Weight-Loss Plan May be Outdated”, where she states that it is no surprise that French fries led the list of foods that contributed to the greatest weight gain. Yet the Harvard study authors go out of their way to emphasize that the results do not suggest it’s about how many calories per French fry (its “caloric density” or calories per serving)—so why draw the conclusion that of course (high calorie) French fries would be high on the list for causing weight gain?

The authors do acknowledge that, “weight stability requires a balance between calories consumed and calories expended…” (although the media fails to highlight this little detail). Yes, they still agree that weight management comes down to calories. But what they hope to define are the foods which are associated with our over consuming calories, along with possible explanations.

What’s it all about?

Harvard School of Public Health evaluated three separate studies to see how changes in our eating and in lifestyle factors impact our weight gain over time. Researchers evaluated self-reported changes in lifestyle factors (cigarette smoking, exercise, alcohol consumption) in addition to changes in individual foods consumed. They looked at three large groups of participants over a 12-20 year period, reassessing every 4 years. They then drew some conclusions and released them in a Press Release and a professional journal article.

Because weight gain creeps up on us (or at least in this study population of non-obese individuals), the authors suggest it is more difficult to know what’s contributing to weight gain, which averaged 16.8 pounds over a 20-year study period. And so they undertook this colossal venture to find us the answers. Well, at least they tried to.

Before I share my reaction to the studies’ results, conclusions and media frenzy, let me state that I have no financial interest in the National Potato Growers Association (is there one, even?).  Or, I might add, with Coca Cola and PepsiCo. But I do have a vested interest in not propagating diet myths. And it is this fear of public misinformation that drives me to invest the time reading the full research article (all 13 pages), which I suspect many of the popular press’ journalists failed to do.

My conclusions on the Harvard study

Servings

Can you guess how much ice cream I ate? And how much I had
from the container before acknowledging I was eating?

Twenty-five years counseling patients and I can assure you that most people are not very adept at accurately assessing their portions. Sure, we can accurately report how many fruits we consumed, but how many chips? Or how much mashed potato? And I’d bet my serving of French fries differs from yours! Ask a dozen different people and you’ll undoubtedly find there’s a tendency to underestimate portions.

That is, unless you are underweight or anorexic; these populations tend to overestimate portions. And beverages are most notoriously challenging for us to estimate (unless of course they are in a marked can). When I have people measure their drinking glasses at home to determine just how much soda they drink, they are shocked. What they assume to be 8 ounces is typically double that amount.

Prepackaged food items and individual units will naturally be more accurately evaluated—individual yogurt cartons and fruits, for instance. Even grains that we tend to measure may be easier to assess, such as oatmeal, rice and cooked whole grains. These very foods that we are more likely to accurately assess our portions of, tend to be lower in calories. Without a doubt, this could distort the study's findings.

Sometimes a potato isn’t just a potato

How do you make mashed potatoes? I’ve heard of recipes that include a whole stick of butter, and some with only half a stick; there are those that add heavy cream and those that add a splash of milk. What’s my point? Did the researchers have information about the contents of these mashed, boiled, and baked potatoes, before concluding that it was the “refined carbohydrate” that was the culprit here leading to weight gain? The study emphasizes that it’s not about calories per serving. But here’s the problem: the serving size is not measured in the study, and we simply can’t make any conclusions about caloric density, if we don‘t even know the content, never mind the quantity, of what’s really in each portion!

Food selection may be a marker for more conscientious eaters

A colleague once said “if she’s eating rice cakes for breakfast than she’s not too serious about gaining weight”. Point well taken. Those who take the time to cook whole grains, such as brown rice, quinoa and buckwheat, are not likely to be the frequent diners at McDonald’s. Perhaps we could say the same for yogurt and low fat dairy eaters. Does anyone start drinking skim milk because of the taste? Eating these foods may simply identify those people who care about their health and the direction of their weight. Weight change may have nothing to do with the individual food itself.

Lifestyle changes they should have assessed

In their next study perhaps they should look at variables that truly impact our weight. Here are a few questions for their next questionnaire:

• Do you eat your potato chips right out of the bag, or do you measure them? 
• Do you have a second and third portion immediately or do you wait to see if you are still hungry? And if you wait, how long do you wait for? 
• Do you reach for food when you are hungry, when your body needs fuel? Or do you find yourself reacting to a triggering conversation with a loved one with some sweets or chips? 
• Do you eat the chips mindfully at the table, without distraction, or are they consumed while driving, watching TV or at the computer screen?

Trust me--these cause weight gain. That is, when you eat them
right from the bag without attention to portion!

These behaviors have everything to do with our weight change. We are less accurate assessing our food intake when distracted. And our mindfulness about hunger and satiety likely gets lost as well. Not eating with all our senses can make us feel like we haven’t yet had our needs met, and so we keep seeking, looking for more food to eat.

Secrets hidden in the Study that nobody advertised

Meat

For all of you Zone Diet and Atkins followers believing that more protein is good and carbs are bad, think again. This study showed that over time, meats, both processed and unprocessed types, were associated with weight gain. So if you are still stuck in the need for more protein for weight management, heed the warning. But remember, this is based on self-reported portions, a potential flaw in this study!

Dairy

So it’s notable to me that yogurt and low fat dairy products as a category (adjusted by age) significantly link with decreasing weight over time. Why notable? Because Walter Willett, one of the study authors, has never been fond of supporting milk consumption. In previous presentations promoting his Mediterranean Oldways Diet Pyramid, he spoke strongly against inclusion of milk and milk products. 


Never shy to ask my questions at conferences, I pressed him on this subject some time ago. His response fell short. He emphasized that some have intolerances to milk, and generalized about milk’s high fat content. And what about low and non-fat diary? And what about Lactaid milk for the intolerant? The majority of the population does not have a milk allergy, so why such an omission of dairy for the general healthy population? Let’s acknowledge that low fat dairy and yogurt are valuable, based on this study’s data.

Diet Soda

There was no meaningful association between diet soda intake and weight change over time. Drinking it isn’t likely to cause weight loss. And contrary to previous media hype, diet soda won’t result in increasing weight either. But it certainly doesn’t add anything nutritionally to your intake. And, consuming it may displace some milk, which definitely does have its merits.

Exercise

Exercise itself didn’t link with weight change, but a change in exercise level did. One more time?

If you’ve been doing the same amount and intensity level of physical activity over years, what happens? Well, think back to when you first started to exercise. It was quite a workout. But after doing it consistently for a while, it got easier. And with greater ease, you weren’t working as hard. And when you weren’t working as hard, you were burning fewer calories. And if you were using up fewer calories, over time, even if your eating remained the same, you would gradually gain weight. For the under eaters and over exercisers among you, let me remind you that you are not at any advantage if you continue to restrict you calories, relative to your need, while exercising. You, too, will suffer, ultimately breaking down the very muscle you aim to increase, and slowing your metabolic rate.

Still reading? Here's the take home message!

So what have the Harvard researchers really taught us? To be critical readers of the media, and of research, for starters. To recognize that studies like these are merely looking at associations, between weight change and changes in foods, and in lifestyle factors. We still don’t know why the link between potato products and weight gain. Maybe if we controlled for serving sizes and preparations we’d see a link with caloric density and weight gain. But maybe not.

Is it me, or do you see a smiley face in my husband's sushi?

I support inclusion of whole grains, fruits and vegetables and yogurt in our diets. But I also know that there’s a place for white, refined carbohydrate sources such as pasta, rice and low fiber French toast. And do I need to emphasize there’s a place for chocolate?

It may be, with more information, we will find some valuable links about foods and their impact on our fullness, affecting our weight over time. But I’d be a lot more cautious, and the media ought to be too, about labeling foods as bad versus good, perpetuating the myth information that causes us to stress eat.