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Thursday, January 31, 2019

Why we shouldn’t demonize formula feeding

Much has been made of the recently published results of the DIETFITS (Diet Intervention Examining the Factors Interacting with Treatment Success) study. Most of the headlines emphasized the fact that the two diets involved — low-fat and low-carb — ended up having the same results across almost all end points studied, from weight loss to lowering blood sugar and cholesterol.

What’s most interesting, however, is how these two diets are similar.

The authors wanted to compare low-fat vs. low-carb diets, but they also wanted to study genetic and physical makeups that purportedly (their word) could influence how effective each type of diet will be for people. Previous studies had suggested that a difference in a particular genetic sequence could mean that certain people will do better with a low-fat diet. Other studies had suggested that insulin sensitivity may mean that certain people will do better with a low-carb diet.
What DIETFITS revealed about weight loss

The study began with 609 relatively healthy overweight and obese people, and 481 completed the whole year. For the first month, everyone did what they usually did. Then, for the next eight weeks, the low-fat group reduced their total fat intake to 20 grams per day, and the low-carb group reduced their total carbohydrate intake to 20 grams per day. These are incredibly restricted amounts, considering that there are 26 grams of carbs in the yogurt drink I’m enjoying as I write this, and 21 grams of fat in my half of the dark chocolate bar my husband and I split for dessert last night.

That kind of dietary restriction is impossible to maintain over the long term and, as this study showed, unnecessary. Participants were instructed to slowly add back fats or carbs until they reached a level they felt could be maintained for life. In addition, both groups were instructed to

    eat as many vegetables as possible
    choose high-quality, nutritious whole foods and limit anything processed
    prepare food themselves at home
    avoid trans fats, added sugars, and refined carbohydrates like flour.

People were not asked to count calories at all. Over the course of a year, both groups attended 22 classes reinforcing these very sound principles — and all participants had access to health educators who guided them in behavioral modification strategies, such as emotional awareness, setting goals, developing self-efficacy (also known as willpower), and utilizing social support networks, all to avoid falling back into unhealthy eating patterns.

Participants in both groups also were encouraged to maintain current US government physical activity recommendations, which are “150 minutes of moderate intensity aerobic physical activity (2 hours and 30 minutes) each week.”
Two different diets that are not so different after all

Get all that? Basically, the differences between groups were minimal. Yes, the low-fat group dropped their daily fat intake and the low-carb group dropped their daily carb intake. But both groups ended up taking in 500 to 600 calories less per day than they had before, and both lost the same average amount of weight (12 pounds) over the course of a year. Those genetic and physical makeups didn’t result in any differences either. The only measure that was different was that the LDL (low density lipoprotein) was significantly lower in the low-fat group, and the HDL (high density lipoprotein) was significantly higher in the low-carb group.

I love this study because it examined a realistic lifestyle change rather than just a fad diet. Both groups, after all, were labeled as healthy diets, and they were, because study investigators encouraged eating high-quality, nutritious whole foods, unlimited vegetables, and avoiding flours, sugars, bad fats, and processed foods. Everyone was encouraged to be physically active at a level most Americans are not. And — this is a big one — everyone had access to basic behavioral counseling aimed at reducing emotional eating.
When it comes to diet, everything old is new again

This whole study could just as well be called a study of sustainable healthy lifestyle change. The results jibe very much with prior research about healthy lifestyle. The end message is the same one that we usually end with:

The best diet is the one we can maintain for life and is only one piece of a healthy lifestyle. People should aim to eat high-quality, nutritious whole foods, mostly plants (fruits and veggies), and avoid flours, sugars, trans fats, and processed foods (anything in a box). Everyone should try to be physically active, aiming for about two and a half hours of vigorous activity per week. For many people, a healthy lifestyle also means better stress management, and perhaps even therapy to address emotional issues that can lead to unhealthy eating patterns. To screen or not to screen for prostate cancer? This remains an important question. Screening relies on a highly imperfect measure, the prostate-specific antigen (PSA) blood test, which is prone to false-positive results. And with mounting evidence that survival benefits from screening pale in comparison with the harms from overtreatment — particularly incontinence and impotence — the pendulum has steadily swung away from it. Still, screening research continues, in the hopes that some lifesaving benefits may be found.

Now the latest study once again casts doubt on PSA screening as an effective public health tool.

British scientists divided more than 400,000 men between the ages of 50 and 69 into two groups: one was screened for prostate cancer with a single PSA test, and the other wasn’t tested for the disease at all. After an average of 10 years of follow-up, prostate cancer death rates in both groups were nearly identical. Cancer was detected more often in the screened group, but mostly it was low-grade, with a questionable need of treatment.

“This was the largest study of PSA screening to date, and the results don’t support it,” said Dr. Michael J. Barry, a professor of medicine at Harvard Medical School, and author of an editorial accompanying the published study.

Called the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP), the study’s approach of giving men a single PSA test differs from the more traditional strategy of testing men repeatedly every few years. However, prior studies investigating repeated PSA tests have reached similar conclusions. One European study with 162,000 men, for instance, concluded that for every life saved by screening, 27 men would be diagnosed and treated for prostate cancer that wouldn’t have been lethal if left undetected.

During the CAP study, 189,386 men were assigned to screening and 219,439 men were assigned to a non-screening control group. After 10 years on average, 549 of the screened men had died from prostate cancer, compared to 647 men in the control group who hadn’t gotten a PSA test. The number of prostate cancer deaths among the controls was higher, but so was the number of men in that group to begin with. So the researchers adjusted for the different sample sizes with a statistical tweak: they compared death rates in terms of person-years, or the total number of years that men in either group had participated to the study. Analyzed that way, the study revealed 0.30 prostate cancer deaths per 1,000 person-years in the screened group, and 0.31 deaths from prostate cancer per 1,000 person-years in the controls, which amounts to a negligible difference.

Dr. Barry, member of the US Preventative Services Task Force, an influential group of independent experts who make evidence-based recommendations about clinical preventive services, emphasized that most men who opt for the test get it more than once. And with each additional PSA test, he said, the odds of being diagnosed with prostate cancer grow higher. “But is repeat screening worth the risk of a low-grade cancer diagnosis and all the treatment complications that come with it?” he asked. “It’s hard for us as clinicians to make those decisions for our patients. We need to make them with our patients to determine if they feel those risks are worth taking on.”

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agreed. “This study adds to the discouraging screening literature, and again, simply does not support screening of asymptomatic individuals,” he said.

Fortunately, Garnick added, men diagnosed with prostate cancer following a PSA test may not have to be treated either in the short or long term. Depending on tumor characteristics, some can opt to have their cancer monitored with active surveillance, which relies on periodic prostate biopsies or MRI to look for new signs that treatment may be necessary. “Hopefully, current research that uses sophisticated genetic testing or biomarkers of prostate cancer may help provide more precise information about those who are likely to most benefit from screening and treatment,” Garnick said. “But we are not there yet.” Improving your diet can seem like a lofty goal, one that people often think requires rigid self-discipline and sacrifice. Cupcakes out, pizza out, treats out, sigh.

But it doesn’t really have to be that way. Sometimes making better decisions for your body can be about adding — not taking away. This may create a more palatable option for those looking for a health boost that feels like a bonus, not a burden.

But what to add? I asked Teresa Fung, adjunct professor in the department of nutrition at the Harvard T.H. Chan School of Public Health for her advice on what foods pack the biggest nutritional punch to a daily diet. Below is her list of five well-balanced options that she says you should eat every day — or at least as often as possible.

1.  Salmon. This oily fish, known for its bright pink color, is rich not only in healthy protein but also in omega-3 fatty acids, which benefit both your heart and your brain. It also provides you with bone-building vitamin D. Still, serving up salmon every day would be a stretch for most people. Aim instead to eat it at least once a week to reap the health benefits, says Fung.

2.  Brussels sprouts. These crunchy little green balls, which look like mini-cabbages, are nutrient-dense and low in calories — only 28 in half a cup. They offer up a well-rounded group of vitamins, including vitamin A, vitamin C, vitamin K, potassium, and folate. Like other cruciferous vegetables, Brussels sprouts feature bioactive compounds, such as antioxidants, which are chemicals that help prevent cell damage inside your body. Taste-wise, Brussels sprouts may be a controversial pick, because while they’re certainly cute, some people find them bitter. If you’re firmly in the “dislike” camp, you can substitute other green vegetables for Brussels sprouts to get a similar nutritional boost. But keep an open mind. You can reduce the bitterness of Brussels sprouts by roasting them with a spritz of olive oil. Add some chopped nuts to the top for a little extra crunch and flavor (as well as extra benefits; see below).

3.  Blueberries. These dark-colored little berries are high in antioxidants, particularly vitamin C, says Fung. Weighing in at 56 calories for 100 grams, blueberries also offer up a good dose of vitamin A and fiber. While most grocery stores will stock blueberries year-round, feel free to substitute another dark-colored fruit — like pomegranates or cherries — if blueberries aren’t in season. Or for some variety, swirl up some frozen blueberries, which taste good at any time of year, with plain yogurt (see below) to make a smoothie.

4.  Nuts. Crunchy and satisfying, nuts not only are filling but also provide an infusion of healthy oils, protein, and vitamin E. Choose any type of nuts: almonds, walnuts, even peanuts (technically a legume), or grab a handful of mixed nuts. Just make sure they’re unsalted, says Fung. But keep in mind these are a high-calorie treat. Depending on the type of nut you choose, an ounce can ring in at 200 calories or more — so limit daily intake to a sprinkling to get the benefits without packing on any extra pounds.

5.  Plain yogurt. This creamy treat gives you a dose of probiotics, which are healthy bacteria that help keep your gut working properly and contribute to better overall health. Yogurt is a nutrient-rich food that fuels your body with protein, calcium, magnesium, vitamin B12, and some key fatty acids that your body needs to stay healthy. And if you choose a high-protein yogurt, it can keep you feeling full, which may help you trim your waistline. While you may prefer flavored yogurts, it’s better to stick with plain. “The problem with flavored yogurt is some of the brands out there have way too much sugar,” says Fung. Sugar negates many of the health benefits of yogurt. Plain yogurt too tart? Toss in some blueberries for added sweetness, says Fung, or add nuts for some crunch. These simple additions can improve the taste, and you can check off three of the foods on this list in one easy snack. Breast is best — we pediatricians say this all the time, because it’s true. Breast milk was uniquely designed for human babies, and many studies have shown its health benefits. In our quest to increase breastfeeding rates here in the US, which are not as high as we want them to be, we encourage new mothers not to use any formula. Hospitals are encouraged not to feed new babies with formula during those first few days before the mother’s milk comes in, and not to send mothers home with samples of formula.

This is all good, as often, if we can get mothers and babies through those first few days and weeks without formula, they can both get used to breastfeeding and make it work. But as we encourage breastfeeding, we need to be careful to keep the big picture in mind and not demonize formula feeding.

In a study recently published in the Journal of Pediatrics, researchers studied babies who had lost a significant amount of weight after birth, which, while common, can be dangerous. They randomized the babies into two groups: one got a small amount of formula after each breastfeeding until the mother’s milk was fully in, and the other group did not. They found that the babies that got the formula were less likely to be readmitted to the hospital, and were no less likely to be breastfeeding a month out.

Exclusive breastfeeding is natural, but not always easy — and when there is a glitch like a delay in the milk supply coming in, inverted nipples, or inadequate milk supply, babies can run into trouble. It’s also not always easy for mothers who don’t have a lot of support from family and health care providers, especially first-time mothers who are feeling overwhelmed, who get sore nipples, who worry that their babies aren’t getting enough to eat. Breastfeeding works best when mothers have a knowledgeable and nurturing community to help them work through the inevitable questions and problems, as well as a supportive work environment, but not every mother has this.

I am not arguing against encouraging breastfeeding. I encourage it with all of my patients, and am lucky enough to have lactation consultants readily available to my practice. I breastfed all six of my children; the last three got only breast milk, while the first three got formula as well, due to logistical and medical issues.

That’s the thing: life and parenting can be complicated. We want more mothers to breastfeed, and we have work to do to make that happen. We need paid parental leave. We need to make lactation consultants and breast pumps available to every mother. We need to educate and inform and build communities (including work communities) that support breastfeeding.

But as we do all this, we need to remember that formula isn’t evil. In fact, sometimes it can be a tool to support breastfeeding — by supplementing newborns that have lost a risky amount of weight, by supplementing the milk supply of mothers who would otherwise give up entirely, by allowing working mothers who can’t pump enough milk for all their hours of work to keep breastfeeding as long as they would like. It’s better that babies get some breast milk than none at all, but if we make it an all-or-none proposition, we may inadvertently cut breastfeeding short.

When we demonize formula we also run the risk of shaming women who, for any number of good reasons, choose not to breastfeed. There are many other ways besides breastfeeding to help babies grow and be healthy; it’s important to keep that perspective.

As valuable as breastfeeding is, there is much more to parenthood than breastfeeding. It’s important to keep the big picture in mind for each mother and baby, and help them both flourish.

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