Why Holistic Nutrition Is the Best Approach

If you are like most people, you may well subscribe to the ONAAT fallacy. I am more confident, however, that you don't know what it is. That's because I just made up the name, although not the concept.

The 'ONAAT' fallacy stands for 'one nutrient at a time.' It's the false, but insidiously persistent notion, that the nutritional quality of a food, or the relevant nutrition guidance for a given patient, can in fact be gauged just that way, one nutrient at a time.

Having devoted years of effort to the development of a nutrition guidance system that can function as 'GPS for the food supply,' providing summative information about overall nutritional quality -- I find the proliferation of so-called "attribute systems" (e.g., this one, this one, and this one and others like them) that call out one or more attributes of a food a potential threat to progress in this area.

My physician colleagues are, with all due respect to our clan, a major reason the ONAAT fallacy was set in motion, and propagated. Because of relative neglect of nutrition in medical education, physicians tend to ignore the topic, or when addressing it at all, to offer limited and discrete advice directly related to their field.

Rather than providing advice about food, let alone the whole diet, cardiologists may be prone to advise against an excess of saturated and trans fat, and dietary cholesterol. Endocrinologists may emphasize avoidance of sugar and refined starches. Gastroenterologists may focus on fiber. Nephrologists and others treating high blood pressure may focus on sodium. And so on. There are exceptions, of course, but the rule prevails.

In my own primary care practice over the years, I have encountered many patients who were trying to follow exactly that kind of dietary advice, imparted by some medical specialist focusing on some particular condition or risk factor. The trouble with "one nutrient at a time" guidance is of the classic missing the forest for the trees variety, or of the even worse "mistaking the part for the elephant" variety. The nutritional properties of a food cannot reliably be captured in any given nutrient level or attribute.

A food may be a source of whole grain, but also a concentrated source of sugar and salt. A food may be low in sugar, but high in salt -- or vice versa. A food may be low in sugar, but a delivery vehicle for trans fat. It may be trans fat free, because it is comprised entirely of sugar and food dyes. Such a food -- gummy bears, for instance -- may be organic, without that signifying anything commendable about its nutritional profile.

Food cannot be judged one component at a time any better than elephants can. What about health?

Here, the fallacy implicit in a one-attribute-at-a-time view of the world is even more obvious. A normal resting heart rate does not rule out multiple sclerosis. A cholesterol value in the desired range does not preclude HIV.

Being free of cancer does not mean good health in someone dying of emphysema. Being free of emphysema would provide scant comfort to someone with advanced pancreatic or ovarian cancer. Being free of cancer would not count as vitality in someone with severe heart failure, or cerebral malaria. Hardly anyone would take pleasure in the robust good health of the left side of their body, while the right side was bleeding profusely.

And then there is the relationship between diet and health, where the fallacy pertains just as well. True, someone with diabetes is well advised to be cautious about sugar, refined starch, and glycemic load. But diabetes, and the insulin resistance that precedes it, is very often accompanied by hypertension -- so this group can't neglect sodium.

And, the leading cause of death in diabetes is cardiovascular disease. So if trans fat and certain saturated fats are of concern in heart disease, they must be of concern in diabetes, and prediabetes, as well.

We know that inflammation is a major contributor to diabetes, heart disease, and cancer and the aging process itself -- and that high levels of insulin can foster inflammation. So sugar, starch, and glycemic load are of concern across the board. Omega-3 fats can reduce inflammation, so they are beneficial to almost everyone.

Dietary fibers can lower blood pressure, and cholesterol, and insulin; can stabilize blood sugar; can improve gastrointestinal health, and potentially lower cancer risk; and can help produce satiety that facilitates weight control. So they are only important for anyone at risk for conditions that cumulatively affect ... at least 80 percent of the entire population!

In short, you cannot use one nutrient at a time to protect one component of health at a time. You can, of course, use foods of high overall nutritional quality, making up a wholesome diet, as a potent defense against virtually all forms of ill health, and a pillar of vitality.

Good food is among the best medicines we have. Good nutrition, like good health, is best viewed holistically. So beware the ONAAT fallacy -- because we are unlikely to get to either good food, or good health, one attribute at a time.

Dr. David L. Katz; www.davidkatzmd.com

www.turnthetidefoundation.org

 

Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz

Comments

[mjgorgeous]

12:30 PM on 04/05/2011

People are overwhelmed with messages of what constitutes best nutritional approaches(from NOT the most reliable sources of information: celebs,on-line marketeers,MDs who have the tunnel vision you allude to), making them vulnerable to the next new diet or one-nutrient craze/supplement promising instant results. I think it's now time to have RDs on staff at every GP practice. So many of today's diseases and conditions are lifestyle-related and doctors are too busy to evaluate and 'diagnose' what's needed diet/nutrient-wise & how to best get a patient to change their diet in order to optimize their nutritional status. Accurate, EFFECTIVE dietary attention is KEY to favorable outcomes in the treatment of so many problems that are seen in GP offices today. If more dietitians were working in GP offices, this would help in the treatment of a disease/condition, relieve acute and chronic problems, prevent exacerbation/progression, and allow for optimal care at the primary level. The cost/benefit of retaining a dietitian has to be worth it when I consider the typical pay of an RD compared to the expense of secondary and tertiary care for so many diseases and problems. Dietitians understand medical concerns, but are also knowledgeable on foods & nutrition, food shopping, preparation, cooking and all the PRACTICAL information that doctors and often, nurses, either don't have or are too busy to get to with patients.
Mary-Jo Overwater, MSc Epidemiolgy, MMSc Clinical Nutrition, RD

[DennyCrane]

11:43 AM on 04/03/2011

The reason so many people buy into the ONAAT mode of thinking is because it's easy. Americans are, for the most part, too easily intimidated. If something sounds even slightly complicated, they won't listen. This is a big reason why so many can't lose weight and keep it off. Losing weight isn't rocket science, but it's hardly as simple as some people make it out to be. For example, the calories in vs. calories out mantra. Sure calories matter. But if that's all that matter, you could eat nothing but junk food and as long as you burned more calories than you consume, you'd never have a weight problem. Common sense should tell you there's more to it. But that's the problem. People don't want to hear that there's more to it. It's the same with nutrition. If I'm lacking Vitamin C in my diet, I can just pop a pill and make up for the deficiency. But tell people that where you get Vitamins matters and that different foods interact with one another to affect how your body absorbs nutrients and they'll quickly throw their hands in the air and say "this is too hard." As for the medical community, the reality is that there's no money in telling people to eat healthy. Why emphasize preventive care when you can make so much more money selling pills that just mask symptoms, performing expensive procedures, and running lots and lots of tests?

[MaryBrighton]

10:34 AM on 04/03/2011

Dear Dr. Katz,
Liked your article and agree with your thoughts. As a registered dietitian, we are sometimes too "educated" on giving standardized advice on nutrition, health, disease with forgetting the following:
Everyone is different, including different genes, environment, culture and social "status".
Thus the "one nutrient at a time" is really a fallacy. As health professionals we should strive towards individual advice geared towards that client/patient that will benefit them to the maximum. Furthermore, sometimes this client needs a multidiscipline approach. As an example, some nutritional advice should be complemented by advice from a psychologist.

Ideally, a person should engage in personal health reform-thus taking care of themselves, not relying on health professionals to solve all their health problems. Plus, in ourselves, seeking a multidiscipline approach for our health. Sometimes we need to see a dietitian, our family doctor, the gym, a psychologist or all, when we are sick. And why not, on a personal level, make a conscious effort to get and stay healthy NOW with, as you said, GOOD FOOD, filled with variety, eaten the least processed possible, local, enjoyed, and not too excess. Great medicine.

Mary Brighton
brightonyourhealth.com

[Tom Sharon]

10:59 PM on 04/02/2011

Want preventive medicine in health reform? Most often the things we never see are in front of us all the time. We all have a part of ourselves that is always there within us and always escaping our attention. This part of who we are, always hidden in plain sight, is the ability to foresee future changes in our mind-bodies as unintended consequences of our behaviors. Therefore, once you read “Health Secrets from the Seventh Heaven” you will realize that the solutions to your existing or potential health problems are so close to you that all you need to do is to become aware of them. More at http://moshesharon.wordpress.com

[DocHeather]

11:16 AM on 04/02/2011

So when will M.D.s start learning about nutrition? Almost all my patients were giving false or no information from their medical doctor about what to eat. Sometimes that is all it takes to 'cure' an chronic illness.

[NancyPeske]

09:03 AM on 04/02/2011

I think it's very difficult for most people to take in the news on the latest nutritional study and incorporate it into their eating plans. There's so much spin and so much conflicting information that they give up. Primary care physicians have little knowledge of nutrition and don't have to keep up on the latest information. So, if you're not sick or don't have disease, it becomes easiest just to give up and eat what you want. Besides, there is far too much shame and judgment out there--"What? You let your child eat THAT cereal?" "Oh my, you are still eating THAT food? Everyone knows it causes cancer." We are not going to get this society eating more healthfully until the shame goes away and people feel they are getting quality guidance--not a confusing food pyramid that's been tampered with by lobbyists.

http://www.nancypeske.com

[SelfAccountable]

11:11 PM on 04/01/2011

Its good to see attention brought to 'whole'istic foods. As someone that was diagnosed with hypoglycemia, I was told that I needed so much protein during every meal if I wanted to not have problems. They didn't talk about cutting out refined sugars, or flours, or adding fruits and vegetables-- actually fruits were told to be avoided because of their sugar and cereal with milk added. But they also didn't mention that all that animal protein, because that was what they were pushing, was also high in fat, and not the good kind.

I went vegan a year ago and the hypoglycemia is gone for good. Fruit is amazing, and has never caused me to have a blood sugar reaction, I pretty much survive off of it, along with my delicious raw vegetables. I encourage everyone to look at the whole of the food they're eating, and if that food is not in its original form, to find out all the ingredients in it and how it came to be through what processes. Cut out the middle man and stick with whole foods and life gets beautiful and healthy.

[RMankovitz]

04:44 PM on 04/01/2011

A nutritional fallacy is the assumption that all of the nutrients found in a “food” are available for assimilation by the human gut. Not necessarily so. Example:

While the urban myth is that bran is healthy for you because it contains more nutrients than the rest of the seed, nature has other plans. Since seeds are the key to plant reproduction, if primates were to devour them in large quantities, it could depress plant propagation. So, nature has placed some anti-nutrients in seeds (and nuts), like phytates, in part to discourage their consumption by us.

Bran is among the highest sources of phytates in food, and acts to bind up essential minerals. The advice to eat bran or whole-grain foods may be a recipe for severe bone loss and intestinal problems due to the high phytic acid content. High-phytate diets result in mineral deficiencies, particularly calcium, zinc and iron. In populations where cereal grains provide a major source of calories, rickets and osteoporosis are common.

Could it be that white flour and white rice are actually “healthier” in the long run than whole wheat and brown rice? For research on the subject, see:

http://www.westonaprice.org/food-features/1893-living-with-phytic-acid?format=pdf

http://www.westonaprice.org/food-features/1896-plants-bite-back?format=pdf

For research on what nature, not nutritionists, evolved humans to eat, see "The Wellness Project."

Roy Mankovitz, Director
http://www.MontecitoWellness.com
A research organization

[Negin Anvar]

09:50 PM on 04/01/2011

Roy, as always, I really do appreciate and enjoy your posts.
Wow. I am surprised about bran. Actually, I had heard about it possibly leading to bone loss, but I didn't want to believe it ... now I'm off to look at the links you've posted. Nutrition can be so confusing. You think you're doing the right thing, then yet another study pops up. I guess balance and moderation are key. I do know that bone health is far, far more related to a plant-based, vegetable diet, than to dairy. Dairy (particularly cow's milk) makes the body more acidic and exacerbates bone loss (as well as causing a whole host of other problems).
Thanks for all this and for the fabulous info you share.

[Finnegans Wake]

12:47 PM on 04/01/2011

Perhaps I'm missing something, but I didn't see fresh vegetables on the value list, only canned and frozen.

And while I like the idea of nutrition being holistic, I'm confused as to how the NuVal system contributes to that. Wouldn't this simply train people to favor the highest-rated foods, thereby narrowing variety? It seems to me that if, say, salmon is the highest-rated fish and broccoli is the highest-rated vegetable, that should not be all one eats. Even if my grass-fed steak doesn't rate as high as the salmon, and my roasted beets are not as highly though of as the broccoli, I still feel better about eating a variety of healthful options.

Also, does the NuVal system place any value on fermented foods or probiotic foods? That should warrant some consideration. I also think there are culinary mushrooms with medical properties (shitaake, maitake, oyster, et al.) that seem to be missing from a lot of discussions on nutrition and health.

[David Katz, M.D.]

02:35 PM on 04/01/2011

I appreciate the comments. NuVal, as noted, has scored 100,000 foods. Among them are many, many high-scoring foods; and quite a few of these, people don't eat routinely. To address your point directly: grass fed beef scores quite a bit higher than grain fed. So, used as intended, NuVal will, indeed, encourage a variety of more nutritious foods. And that, in turn, is the means to a more healthful diet overall.

As for some of the other issues you raise: they are not yet routinely captured in any measure of 'nutritious.' There is no recommended intake, per se, of specific mushrooms, or probiotics. As we work on ONQI 2.0, such considerations are in play. But we also recognize that trying to do too much with any one tool- is apt to break the tool. NuVal measures nutritiousness; there are, and always will, other considerations about foods that matter, too.

[Endotoxin]

04:52 PM on 04/01/2011

It's simpler than most people think.

Everyone's biology is different. Everyone has slightly different nutritional needs calibrated to their own DNA.

If you FEEL good long-term (and I'm not talking sugar or alcohol spike, i mean over the course of a few hours after the meal or food has been consumed) most likely what you ate is good for you.

Taste is not an indicator of nutrition. This is what Americans have to realize.

[ncyim]

08:56 PM on 04/01/2011

Agreed. Cultural nutrition = what your ancestors ate is critical. I would extend the possible effects of food eaten to 72 hours if there is an immune reaction.

[BluzySuzy]

12:22 PM on 04/01/2011

Dr. Katz:
Why don't more primary care physicians embrace this kind of thinking? I am currently following the new Weight Watchers Points Plus system for eating, and it seems like it is based on a holistic approach to nutrition. Alot of the followers online complain about how much more slowly they are losing weight, but I think it is because I am eating a balanced and healthy diet very similar to what I will be eating when I enter the maintenance phase.

[w84it]

04:20 PM on 04/01/2011

Loosing weight slowly is a good thing! Your chances of maintaining your goal weight will be much, much better. :)

[Terri Lorz]

10:56 AM on 04/01/2011

Thanks - Terri Jo Lorz

[w84it]

09:47 AM on 04/01/2011

Dr. Katz, I've gone to the NuVal website a couple of times and I really like the idea of identifying the nutritional value of particular food. How does one learn to combine nutritious foods in order to have a balanced and holistic diet that meets their particular needs?

[David Katz, M.D.]

10:01 AM on 04/01/2011

Thank you. And, for what it's worth, I am encouraging NuVal to offer a fully interactive website that allows people to look up scores for the roughly 100,000 foods now in the database (as a by-product of generating NuVal scores, we have created- by far- the world's largest, most detailed, and most current nutrient database). I am hoping this will happen within the year!

Two responses to your question:
1) we have built a derivative of the Overall Nutritional Quality Index algorithm for total diet scoring. It provides a running tally for diet quality, based on the nutritional quality of individual foods, and measures for balance, variety, etc. It is in testing, and we hope to make it available for general use within the year as well

2) in the interim, the best bet is to use sensible guidance about overall diet composition- such as that offered by the IOM or US Dietary Guidelines, or NHLBI, etc.- and use NuVal to choose the best foods to populate that pattern

NuVal is a very powerful tool- but as an amateur carpenter, I know very well that no tool- no matter how good- can do all jobs. NuVal is great for trading up individual food choices; other tools are available to characterize recommended variations on the theme of a healthful dietary pattern. The two are complementary.

Best,
DK

[photocyte]

12:19 PM on 04/01/2011

How does NuVal compare to the ANDI score?