Why are People So Confused about Nutrition?
“Emotions are not reactions to the world, they are your constructions of the world."
-Dr. Lisa Feldman Barrett
One of the most challenging components of nutrition itself is undoubtedly the confusion surrounding nutrition science. The relentless stream of misinformation, myths, trends, and axioms that are rooted in little-to-no scientific evidence is so severe in nutrition, that its now actually a topic of research itself! A recent study by Marton et al examined the "advocacy and quackery" in the top 100 nutrition books and investigated all major claims in each book plus the authors themselves.
Here are some key takeaways from what they found:
Entrepreneurs, trainers, physicians, actors, bloggers, and "other" non-nutrition-related occupations constitute 64% of the pool of nutrition book authors
Those who study nutrition at the graduate and research levels, such as Registered Dietitians and Biochemists, were barely 6% of authors
One author was listed by "Quackwatch" as an individual who "promotes questionable methods/advice"; another was investigated for research fraud and then retired; one author lost his license to practice medicine and was investigated by the DA of NY for promoting unfounded health practices; another author received letters of warning from the FDA; and another was convicted for misrepresenting the content of his books, among some other crimes, and went to jail
The authors of this study concluded that "the large majority" of the top 100 nutrition books "contain substantial misinformation and claims that have no scientific foundation."
Oof. This is a serious problem. But how do we solve it?
It won't be solved easily. There are several factors at play that keep this strange intersection of nutrition and pop-culture flowing so strongly. The first is that individuals who build large platforms (like huge blogs and TikTok accounts) that allow them to publish books usually have the time to do so--which means they are not with clients, patients, teaching, or working in the lab. So by default, they are people who have a small professional life (or none) in nutrition research or treatment.
Speaking anecdotally, at times it has felt impossible to post to social media or stay on top of even small operational things for my practice because I'm with patients all day, everyday (there's no big TikTok boom coming for me!). And some of the absolute best clinicians in the world--including some physical therapists and psychotherapists I know personally--do not even run a single social media account. Because they're treating all day! As consumers become aware that its important to investigate an author's credentials as well as their professional reputation, there may be some shifts in which nutrition claims/books/products get the most traction.
A second key component of this issue is the manner in which most of these most popular books also sell "quick fixes" that American consumers continue to devour. Diets, meal plans, elimination protocols, and supplement plans that last 30 days are a lot more exciting, and easy to follow, than the mental and emotional work of a lifestyle overhaul. Yet, we see in nutrition research that emotional regulation, lifestyle interventions, culture, environmental engineering, and identity are the most powerful forces in someone's food behavior. But there's no books on these topics! Because there's no way around it: those changes require work. Consumers typically don't find those ideas approachable and publishers have no interest in printing books that only a small subset of the population may purchase.
As the concept of nutrition shifts in our culture (which starts at home, in our own minds), and we view it as a lifestyle, and as a component of our emotional wellbeing, social time, and self-care, the "quick fixes" from an entrepreneurial blogger may become less and less of a force in our food life. This will help us feel less confusion and overwhelm, and finally have the space to build something far more nourishing and sustainable.
The Critical Cholesterol Marker
For decades, most routine doctor's appointments have consisted of a physical plus a basic metabolic panel of lab work. Usually, this also contains a lipid analysis. We receive back readings on cholesterols, triglycerides, and HbA1C, listening to our doctor rattle-off numbers and warn us about how one of them (LD-something-or-other?) is getting too high so we should lose ten pounds. If you're like many of my patients, you might leave those appointments wondering what the heck your doctor was talking about and feeling unsure if you should be concerned. On top of that, we're now seeing some doctors run an additional lab called "apoB" and this is raising more questions about cholesterol management itself.
So what is cholesterol, what do those labs mean, and why are some of these protocols recently starting to change?
Lipids are a class of molecules that are not soluble in water (imagine pouring olive oil into your glass of water--they wouldn't mix), and therefore they cannot circulate freely in our bloodstream. Because of this, lipids must be carried by a school bus of sorts--these are called lipoproteins. Lipoproteins consist of triglycerides (loose fats) plus cholesterol particles. A substance called apoproteins wrap each of these lipoproteins in a protein coat (this is the protein component of lipo-proteins). We classify these lipoproteins by their density. They are:
Chylomicrons (extremely loose and fatty)
Very-low-density lipoproteins (VLDL)
Intermediate-density lipoproteins (IDL)
Low-density lipoproteins (LDL)
High-density lipoproteins (HDL)
Within the related classes of LDL, there are particles like "lipoprotein little a" (Lpa, for short)
We also classify lipoproteins based on their protein coats--their apolipoproteins--which are mostly labeled as either apolipoprotein A or apolipoprotein B (apoB). Its like some types of cholesterol all are wearing red jackets, and other types are all wearing yellow jackets. And we really want to know how much of each we have.
As it turns out, HDL--the health-promoting and protective cholesterol molecule--has a protein coat consisting of apoA proteins only. Whereas chylomicrons, VLDL, IDL, LDL, and Lpa all have a protein coat of apolipoprotein B (apoB). These cholesterol particles are all known to be atherogenic--meaning, they can contribute to the formation of atherosclerotic plaque in arteries. This means that measuring apoB effectively measures the presence of all atherogenic particles in one's bloodstream.
Several large review studies are now describing the importance of directly measuring apoB instead of the more typical assay that assesses LDL, HDL, and total cholesterol. The apoB measurement is a broader-spectrum measure of all potential risk, and is more accurate than the calculations that are often made to estimate someone's cholesterol.
Directly measuring apoB may be the most effective measure of potential risk because its a large-scope measurement of all atherogenic particles. It's akin to measuring all of the traffic jams on a highway (your blood) instead of calculating how many cars might be on the road. If we can determine the traffic jams with more specificity, we can strategize about how to open up the roads and keep things flowing more efficiently. The interesting thing is that right now in the United States, apoB is still not a common, routine measure. Some doctors are electing to capture it in some practices, and others are not. If possible, its important to ask your doctor about this (if someone's doctor will not run it, I do like to order the lab as a nutritional marker that we can track in tandem with our interventions).
In addition to aggressive lifestyle changes--like smoking cessation, significantly reducing alcohol intake, improving insulin resistance, building lean mass, moving and sleeping more, dramatically increasing fiber intake, and cooking more at home--lipid-lowering statins and some bile sequestrants all have been shown to lower apoB, which effectively lowers risks for adverse cardiac events. As research continues to emerge on the most effective way to detect and alter heart disease risk, we can more precisely and aggressively treat the greatest threat to American health. Just remember: advocate for yourself at all of your appointments. A lot of new research and nutrition-related interventions often don't trickle down to practicing medicine very quickly, so always ask questions and be vocal!
Genetics are Inherited, and So Are Behaviors
I recently taught a lecture on the effects of culture and development on nutrition, and how research has been finding associations between what we learn when we're developing and how that manifests in our food beliefs, habits, and identities once we're adults.
For example, studies have found interesting connections like:
If a parent eats past the point of being full, their child is likely to do that consistently by the time they're 18
If a parent demonstrates a preference for "ultra-processed" foods (pizza, ice cream, fast foods, pastries/sweets), a child will typically demonstrate the same preferences before they're 10
If a child has meals in a household where (1) caregivers eat the meal with the child, (2) caregivers eat vegetables and whole foods at the meal, (3) vegetables and whole foods are provided to the child at the meal, and (4) the caregiver is emotionally available at the meal, the child is in the lowest risk category for emotional eating, binge eating, and metabolic disturbances at age 18
If a parent partakes openly in dieting, weighing oneself, and restricting/binging certain foods, the child is in the highest risk category for participating in dieting, emotional eating, or nutrition derangements by age 18
After the conference, I had many attendees approach me with follow-up questions about how and why this happens. People shared that they felt alarmed at how they much they eat like their parents, even though they don't want to. Or that they 'diet just like their mom did,' or cook the same foods that they grew up eating--even if they don't want to diet, or want to learn how to cook new things.
Everyone wants to know: why is this happening? Is being a bad cook just in my genes? Is being a yo-yo dieter in my genetic code?
Thankfully, not quite. Science examines the ways that our genes directly influence parts of us, but we also know from behavioral research that genes aren't the only thing running in families--behaviors do, too.
If we think about the way our brains work while we are growing during our sensitive formative years, it makes perfect sense. Human children are designed to be highly sensitive to their caregivers, and to pick-up on everything they are told, overhear, witness, receive, or don't receive. Our little brains then turn that into a set of core stories, identities, and norms that create the software programming for our brain.
As an example, think about if you grew up in a place where everyone comes home for all three meals every single day (like my family members from Brazil), you might find it strange that Americans eat takeout at the office in front of their computers. Or let's say you grew up in a household where weight was discussed frequently, constantly monitored, and focused on. You might find it impossible to imagine not worrying about bodyweight (your own, as well as others). See the way these things become "norms"-- the framework itself that holds our thoughts and shapes the world?
There are many behaviors and ideas that we can inherit that serve us and help us thrive. And there usually also are some that cause us pain. When it comes to our health, I typically hear most about all the behaviors that someone wants to shed. We want to create something new--yet we have so much inner friction to new thinking because it feels so foreign. It challenges our identity, it might require us to be more personally responsible, and it might require us to examine things we don't want to look at. But not doing this is exactly what perpetuates generational behavior patterns. Its exactly how we unconsciously repeat the pains of the past, and live-out the dysregulated behaviors that we wish we could break free from.
When speaking on generational behavior, the wonderful therapist, Vienna Pharaon (author of "Origins of You," an absolutely amazing book), writes: "There are people in your life who will pass the pain instead of healing their own. There are endless reasons for this, but regardless of what is true, it is for you to decide whether someone else's unintegrated pain will become yours or whether you will use it as a catalyst for your own healing. Family pathology rolls from generation to generation like a fire in the woods, taking down everything in its path, until one person in one generation has the courage to turn and face the flames. That person brings peace to his ancestors and spares the children to follow. And so I ask...will that be you?"
When we look at all facets of our development--including our nutritional development--we see that much of what we inherit is not just genes themselves, but attitudes, beliefs, habits, and ideas. Many of us discover that we have some behavioral patterns that are causing us harm, whether its emotional eating coping strategies, use of alcohol, fear of the kitchen, self-shaming, disordered eating, debilitating perfectionism, and other hinderances.
The first step to unlocking these unconscious patterns is to become conscious to them. When we bring them into our awareness we can witness ourselves with more accuracy and curiosity. We can observe what we're doing, and trace the thought/behavior to where it came from. Arguably all behaviors have origins, so it can be incredibly eye-opening to engage in this process. Then, we can explore whether or not that behavior is serving us and begin the journey of deep behavior change if we determine that it is not. Through exposure, rewiring, and building new "software programming," we most definitely can change the way our mind is working. When we engage in this process, we also will shift our identity, express new proteins in our brain, and build new frameworks for habits and attitudes. Overtime, this is how we create healing and change for ourselves. I have the pleasure of seeing it everyday in my work.
So many of my brave clients have been cycle-breakers themselves, and it has been an honor to witness their journey as they redesign their food framework, show up at family gatherings in a new way, set a boundary around body-talk, throw out the scale, sign-up at the gym, advocate for themselves, or feed their children nourishing family meals. Its amazing what someone can do when they turn towards their story and pick-up the pen for themselves.
I love the power that we hold to be something new and write a new story. Will we pass the pain, or be the one to end it?