In the week in which Alexander Rinnooy Kan, one of the most influential opinion leaders, in a contributed piece in the NRC advocates a (mild) neoliberal policy for public health in the Netherlands (“all parties must take their responsibility”), a medical institute in the United States, which is known for being conservative, calls it a ‘public health imperative’. It is an obligation on the government to not only promote healthy eating, but also make it accessible to all walks of life, says the American Heart Association (AHA).
That the AHA is speaking out about the ‘misinformation and systemic problems’ in the food supply is one of the surprising topics in the 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. In the many previous expressions of the AHA, the white coats were especially audible.
Not so much what we eat, but also the ‘why, how, where, how much and why?’ of the daily and lifelong diet determine health
“Racism, social segregation, food insecurity and targeted marketing” are not the issues cardiologists should be complaining about in the first place. But in this guidelines for a ‘heart-healthy diet’, the American sister of our Heart Foundation draws explicit attention to this.
Not so much what we eat, but also the ‘why, how, where, how much and why?’ of the daily and lifelong diet determine health. Of the heart, and therefore of the whole person. After old age, so-called ischemic heart disease (due to atherosclerosis, arteriosclerosis) is the largest cause of death worldwide. Nutrition is a determining factor in this.
The word lifestyle was added to the Diet and Lifestyle Recommendations Revision 2006, because “this scientific statement emphasizes the importance of dietary patterns alongside individual foods or nutrients”. That was already a broader perspective on nutrition than that from 2000, in which the normative could still be expressed in percentages and milligrams. Entirely in line with the medical and reductionist view of nutrition that applied at the time.
In the new guidelines, almost all of the well-known, old-fashioned recommendations still apply. Those are the well-known rules: reduce saturated fat, sugar, alcohol, salt. Also with refined carbohydrates and the trendy coconut fat. “Achieve and maintain a healthy body weight”, is the first of ten ‘features’. The fact that for many people the control over their body weight is beyond their will and ability is no reason for the strict authors of the guidelines not to make this the first requirement. ‘If you don’t want to have a heart attack, lose weight first’. you hear the old skool doctor say.
The major turning point that AHA is making is that the context (‘chain’ or ‘system’) of the daily and lifelong diet determines the real influence of nutrition on (heart) health. More than the choices that an individual could make of his own free will and/or with his mind. The changes suggested by the AHA fall within that context, for which you can also read ‘offer’. Healthy food does not mean suddenly eating a lot of vegetables or taking vitamins. Replace ‘bad’ foods with ‘healthy’, is the message. Eat fiber from brown bread, vegetables, beans, instead of white bread, rice and fast food. Eat lean meats and dairy, no saturated fat. Don’t drink sugar.
Actually exactly like the food change of our Nutrition Center. (You do run the risk of going bald and having a strange taste for shirts; see the photo on the VC site).
“The emphasis is on dietary patterns, not specific foods or nutrients,” thus Alice H. Lichtenstein, lead author of the guidelines, in USNews. “[Z]Either the increase in one food ingredient or the decrease in another may have independent effects. What’s really important is the balance of everything together, which has the biggest impact on cardiovascular health.”
The AHA states in the explanatory notes that the latest insights from nutrition have been taken into account when drawing up these guidelines. In the first place, this concerns the shift from what is called substance thinking to recognizing the complexity of nutrition, as a ‘matrix’ of influences that cannot be seen or predicted in isolation from each other.
That insight became clearer between 2006 and 2021 and processed by AHA. The scientific part of it is often still soft, the AHA admits. Still, AHA recommends eating mostly plant-based proteins and keeping highly processed foods, UPFs, to a minimum. Those are remarkable recommendations for an institution that certainly didn’t seem to be ahead of the curve in the past.
This calls for a different approach to public health than the usual reference to personal responsibility. That is not only remarkable, but also brave for an American institution
And there’s that other big theme that the AHA broaches. It can be summed up in one word: inequality.
The AHA notes: “Despite widespread knowledge about the components of a heart-healthy diet, the United States has made little progress in meeting nutritional goals. Differences in nutritional quality by income, race and ethnicity, education, and use of food aid programs are well documented, but little action has been taken to reduce the disparities that contribute to sub-optimal food quality.”
The AHA has in the past criticism because it received a lot of sponsorship money from the food industry. However, the ‘writing committee’ of these guidelines extensively emphasizes (and documents) independence. Anyone who reads the piece with suspicion will have to make an effort to find traces of influence. There will always be discussion, about saturated fat and cholesterol in particular.
In addition to being a nutritional guideline, this piece can also be read as a welcome analysis of the problems surrounding daily fare. The question is to what extent the seriousness of the AHA’s appeal to the American government is consistent with the Dutch situation. Are ‘racism, social segregation, food insecurity and targeted marketing’ among us also factors that deteriorate the health of certain groups through eating habits?
Yes of course. It is known that the socio-economic status of citizens directly correlates with their health. Perhaps less polarized than in the United States, where many people already rely on fast food and ready-to-eat food for more than half of their diet. Targeted marketing, especially to children, is a recurring point of irritation. Just think of the vegetable sweets from (butcher’s daughter) Nicolette van Dam.
Of the ten ‘features’ in which the AHA packages the new insights (see box), the last one is noteworthy: ‘Stick to these guidelines, regardless of where the food is prepared or consumed.’ Because so much of the daily food does not come from your own kitchen, it is crucial to maintain the standards that you set when cooking for yourself for ordered meals. Every day, for a lifetime, the AHA says. In practice, this amounts to a daily exercise in hostile territory, that of the oversupply and overstimulation of unhealthy food in the living environment. That is the sphere of activity of governments, who can do a lot of good there.
2021 Dietary Guidance to Improve Cardiovascular Health offers a critical, but also nuanced view of the rapidly changing food environment. This calls for a different approach to public health issues than the usual reference to personal responsibility. That is not only remarkable, but also brave for an American institution, which has to gain the favor of donors and sponsors. But the truth must be said.
- Adjust energy intake and expenditure to maintain or achieve a healthy body weight.
- Eat plenty of fruits and vegetables, choose a wide variety.
- Choose foods made primarily from whole grains rather than refined grains.
- Choose healthy sources of protein
a. mainly proteins from plants (legumes and nuts)
b. fish and seafood
c. low-fat or fat-free dairy products instead of full-fat dairy products
d. if meat or poultry is desired, choose lean cuts and avoid processed meats.
- Use liquid vegetable oils rather than tropical oils (coconut, palm), animal fats (eg butter and lard) and partially hydrogenated fats (trans fats).
- Choose minimally processed foods instead of highly processed foods (UPF).
- Keep your intake of drinks and foods with added sugars to a minimum.
- Choose and prepare foods with little or no salt.
- If you don’t drink alcohol, don’t start it; if you choose to drink alcohol, limit its intake.
- Follow these guidelines no matter where the food is prepared or consumed.
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‘Good nutrition is government’s job’ – American Heart Foundation makes remarkable statement – Foodlog