No wonder we are all exhausted: our dietary guidelines are causing malnutrition

Have you been attempting to follow national dietary guidelines?

I perform quite a lot of dietary analyses on people. In fact all of my 1-to-1 coaching clients have to send me a 3 day diet diary that includes everything they eat and drink. And when I feed back the analysis they are usually stunned, because everyone is malnourished.

But that isn’t really what stuns them. They are stunned by the fact that I almost always have to tell people that they need to eat more food. A lot more food. And that the reason they have such severe dietary nutrient deficiencies is because they’ve been trying to follow dietary guidelines.

Every year the nutrition habits of a selection of people in the UK are reported on. Every year the results get a little bit worse. Every year in the UK we are becoming a little bit more malnourished. 

But why is this? Is it because we get worse at following dietary guidelines year after year? Read on to find out.

Ever heard of the National Diet And Nutrition Survey?

In January 2019 the most recent National Diet and Nutrition Survey for the UK was released.

It analysed dietary intakes, and some blood and urine results for the UK population for the 9 year period from 2008 to 2017.

Each year a sample of 500 adults and 500 children over the age of 1.5 years was selected to participate in the study.

Assessment involved an interview, a 4 day food diary, physical measurements, and urine and blood samples.

People were analysed in age groups which roughly fell under the categories of:

  • preschoolers,
  • primary school age children,
  • secondary school age children and young people,
  • working age adults and
  • seniors/retired adults.

The British Dietetics Association (BDA) were overall rather pleased with the report, because it shows that people do listen to Public Health advice and attempt to modify their diets accordingly.

Summary of the main findings

  • Energy intake fell ever so slightly, especially in primary school girls and secondary school age boys. So much for us all eating too much because we are greedy.
  • Total fat intake held steady as a percentage of energy intake, and was generally within the 35% recommended range. So we can’t be getting fatter because we are eating too much fat. (According to the study only one fifth of senior men, one third of working age men, one third of senior women, and two fifths of working age women now have BMIs which are considered normal. While while more than one third of boys, and almost one third of girls are either overweight or obese)
  • Saturated fat intake also remained steady. But they were disappointed in people having a saturated fat intake that was greater than their recommended 11%. Clearly they think we need to get rid of even more healthy, natural foods rich in fat and replace them with rancid, cancer-causing, industrial vegetable oils like soybean oil, despite the lack of evidence that this is a good idea for anyone of any age. Should we all be trying to increase our intake of canola oil when there are no long term studies done yet to address important questions like “will canola oil help me to live longer?”, or “will canola oil stop me from having a heart attack, or a stroke, or Alzheimer’s disease, or depression, or improve my energy levels?”, or “how does it affect any of the modern day health scourges that are causing so much misery, disability and death?” 
  • Intakes of proteins and carbohydrates didn’t really change much either, although protein intake in seniors did fall a bit.
  • The intake of trans fats also lowered, and fell within their recommended range of <2% of energy from food. They felt very proud of this accomplishment. This may be a little ironic, since it was government recommendations to replace naturally occurring saturated fats from real foods (particularly classics like full fat dairy and animal products) that created the trans fat crisis in the first place.
  • Fruit and vegetable intake remained pretty stable (the consumption of vegetables for adult men of working age increased slightly year on year, and their consumption of fruit also went up marginally), with downward trends in the consumption of fruit juices, particularly in women of working age, primary school children, and girls of secondary school age. It appears that people are getting the message that fruit juices are high in sugar and very low in nutrients. People in higher income households drank more fruit juice than those in lower. Public Health England (PHE), who authored the report, and the BDA were of course disappointed that people are still not meeting their completely arbitrary target of 5 pieces of fruit and vegetables per day.
  • The intake of fibre fell very slightly in children, and rose very slightly in working age men. Overall fibre intakes didn’t really change very much. People still aren’t consuming as much fibre as the government would like them too. It’s amazing we need a sewage system in this country at all, or plumbers to unclog toilets, since apparently we must have collectively stopped pooping due to fibre deficiency.
  • The intake of total meat and white meat stayed steady throughout the period.
  • The intake of red and processed meats has been falling, so this pleased both PHE and the BDA, despite the complete lack of any reliable evidence linking unprocessed red meat with adverse health outcomes. And reducing intakes of unprocessed red meat has resulted in increased micronutrient deficiencies (more on that later). They pointed out that adult men still consumed more than their recommended 70g of red meat and processed meat every day. This appeared to disappoint them.
  • The intake of oily fish did not change much throughout the study period, although higher income households consume more than lower income households.
  • The proportion of children consuming sugar-sweetened soft drinks fell by 26% in pre-schoolers, 35% in kids in primary school, and 17% in secondary school age children. Among children who were still drinking sugar sweetened beverages, the amount that they consumed also fell. This was obviously considered a win. But what were they replacing sugar-sweetened soft drinks with?
  • The intake of free sugars fell in both adults and children (more so in children), with children under the age of 9 meeting government recommendations of <5% of energy intake.
  • In higher income families the intakes of total fat and saturated fat increased for adults, but decreased for preschool children, compared with lower income families.
  • There was a downward trend in the percentage of people over the age of 11 years old consuming alcohol, but particularly in working age adults, and in secondary school age girls. In unrelated news, did you know our teenage pregnancy rates have also been falling?

What has been happening to nutrient intakes over this 9 year period?

Intakes of several key nutrients fell over time, resulting in an increased risk of malnutrition.

In particular falls in vitamin A, iron, vitamin B2, folate, and zinc, with continued worrying low intakes of selenium were noted. These are all nutrients found in abundance in liver, and a few of them are also found in excellent quantities in red meat.

The increasing malnutrition has very serious implications for girls and women who are having (or are thinking of having) babies

Looking at women of roughly, kind of, sort of childbearing age (11 years to 64 – they didn’t actually look at premenopausal and postmenopausal women separately, apart from for folate blood levels, despite the fact that this would be kind of useful to do), there were very worryingly low or borderline levels of many key nutrients that are important for fertility, pregnancy and lactation. The requirements of these nutrients increase during those periods as well.

Portrait pregnant woman
Photo by Laura Fuhrman on Unsplash

What's been happening with vitamin A intakes?

Vitamin A intake has been falling in all age groups, but adolescent girls have particularly poor intakes.

Why should you care about vitamin A?

Vitamin A is really important for the immune system as well as for calcium metabolism, with implications for how well we grow the skeletons and teeth of our babies, and keep them strong throughout life.

Vitamin A deficiency is actually what is responsible for a very large proportion of measles deaths worldwide, which is why the WHO recommends giving megadoses of vitamin A to infants and children in developing countries as soon as they develop measles. So paediatricians, please remember this the next time you see a baby with measles. It will take you a lot less time to read the WHO guidance on vitamin A for measles than it will to work out whether the baby’s mother had adequate active vitamin A intake before and during pregnancy and during breastfeeding. Or to try to work out whether or not she is good at converting beta-carotenes into retinols. Of course you can always check a blood level of vitamin A, but if you hang around waiting for a level to come back before you decide to treat the baby, it might be too late to save their life. But you should have a very high index of suspicion for anyone having a vitamin A deficiency, given that the top 2 sources in the diet are liver and cod liver oil, and most pregnancy supplements contain no active vitamin A at all (they mostly only contain beta-carotene).

Synthetic retinols have been associated with an increased risk of birth defects in one study, but eating liver was not. You probably should avoid eating polar bear, seal or husky liver, but apart from that liver has been consumed reasonably safely all over the world for thousands of years without the need for dietary guidelines giving it a bad name. In case you’re wondering, commercial retinol synthesis is a complicated process that involves multiple steps, catalysts that use bromides and/or heavy metals and creates some unwanted products that are supposed to be removed at the end of the process. Which begs the question, could some of the increased toxicity seen with synthetic vitamin A be a result of contamination from the manufacturing process?

In the current climate, it's also worth considering the role vitamin A has in the immune system.

Recently, there’s been a lot of focus on how viruses affect health. In addition to the usual concerns about influenza, there’s been increased increase in coronavirus infections, especially COVID-19. I’ve already mentioned the measles virus above and pointed out that measles mortality in children is closely related to hypovitaminosis A.

Vitamin A plays a crucial role in our mucous membranes. You’ll find mucous membranes lining your gut, mouth, nose, sinuses, lungs and all through your respiratory tract. You’ll also find them in your bladder and throughout your urinary tract. Mucous membranes form a moist, warm interface between your bloodstream and the outside world. So it’s important that you defend them from invaders. That’s where retinol and other active vitamin A molecules (retinoic acids) come into play.

We know from animal studies that important immune cells that produce our antibodies (called B cells) as well as white blood cells called T cells or T lymphocytes can’t function properly when there is vitamin A deficiency. These cells are key players in what’s called our adaptive immunity. This part of the immune system recognises and targets very specific threats. Clinical trials looking for a response to vaccines typically measure antibodies and now with COVID-19 vaccines, they’re also starting to measure T cell responses to novel COVID vaccines. In fact, vitamin A has been shown to enhance antibody response to vaccines as well.

There’s another part of your immune system that’s equally important but less specific. And that’s called adaptive immunity. Your adaptive immune system is made up of a lot of other types of cells, like natural killer T cells, macrophages, and neutrophils. These cells need retinoic acid to mature.

Why is this important?

For a couple of reasons. One being that when you have an infection, you might find that you’re losing vitamin A in your urine. But the most important reason is that clinical trials using both animals and humans show that giving supplemental vitamin A during infections with diseases like measles, infectious diarrhoea and malaria saves lives and reduces symptoms. Human studies show that vitamin A deficiency is common among people suffering from tuberculosis. And one of the treatments fro TB in the early twentieth century was cod liver oil, which is one of the best sources of vitamins A and D. Of course, liver is the best natural source.

Unfortunately, mainstream medicine appears to have forgotten most of the lessons learned during the last century about how our bodies use nutrients, including the fat soluble vitamins A, D and K. We’ve fallen for the unfortunate triple whammy of believing that:

  1. nutritional deficiencies are now rare because of dietary guidelines and food fortification of grains (this is false. Nutrient deficiencies are endemic),
  2. nutrients are essential, but only to prevent nutritional deficiencies that we don’t see anymore. We’ve forgotten that nutrients are essential because every cell and organelle inside our bodies needs them to function at even their most basic level,
  3. malnutrition doesn’t increase your risk of infections (the way that people with classical malnutrition (including scurvy, beri beri, pellagra, vitamin A deficiency, and protein energy malnutrition) die is from overwhelming infection and/or organ failure. 

Perhaps you’ve noticed an increase in nutrient supplements like vitamin D, vitamin C and zinc since the start of the coronavirus pandemic. There are even a lot of clinical trials running or planned looking at cholecalciferol, zinc, and vitamin D on their own or in combination with each other or with medications. Unfortunately, the high dose ascorbic acid (vitamin C studies) for severe COVID-19 are only giving it for 4 days and then stopping. It needs to be continued until people are well on the mend and then gradually titrated down.

But almost everyone seems to have forgotten about the role of retinoic acid in the immune system. Particularly in combination with the other fat soluble vitamins D and K2. There is so far only a single review article that I’ve seen that mentions vitamin A and its importance for the immune system in the context of COVID-19. But now that you’ve read this and you’re aware that your immune system cannot and will not function properly in the absence of vitamin A, you’ll know to make sure that you include it in your diet regularly. Because even though you can store a lot of vitamin A in your liver, when you get sick you lose a lot in your urine. You need to keep consuming it frequently. And you’ll also know where to find vitamin A in your diet and you’ll know that you can’t rely on carotene from plants. You need to get your vitamin A from liver or a good quality cod liver oil.

Surely people are getting enough folate? No? Really?... Oops

Why should we care about folates anyway?

Folates are very important for metabolically active tissues, like the nervous system, which is why a deficiency in them can result in spina bifida.

Unfortunately synthetic folic acid added to flour actually has zero folate activity without conversion in the body to natural folates. Conversion can be incredibly challenging for a lot of people, especially in the presence of vitamin B2 deficiency (which was also on the rise in this study in children, older women, and adolescent girls).

Where can I find more folates in my diet?

Natural, active folates are found in large amounts in liver, legumes and leafy greens, 3 foods which are not necessarily high on many people’s favourite foods list.

Lentils and meat - real food
Photo by Louis Hansel on Unsplash

Just because dietary intake might be decreasing doesn't mean that people are deficient though. What evidence is there that more people are deficient in folates?

Blood levels of folates fell by over a third over the 9 year period in women of childbearing age. In fact the proportion of women with a folate deficiency on blood testing jumped up from around two thirds to almost 90% of women. That is a pretty petrifying statistic.

What about the intakes of other nutrients?

Intakes of iron and iodine, 2 nutrients that are pretty vital for normal nervous system/brain development in babies and children, and pretty handy at all stages of the life cycle, are also on the way down. As are magnesium, calcium and potassium. Seniors also saw increasing levels of iron deficiency and a downward slide in their haemoglobin levels to match their low red blood cell folate levels.

Did the blood tests pick up any other nutrient deficiencies?

Blood tests suggested that riboflavin (vitamin B2) levels are also on the way down, and that vitamin B12 levels are also falling in some groups. Extremely low blood levels of vitamin C, which were in keeping with scurvy, also increased by 6% over the 9 years in adult women of working age.

Raw Steak on ice - real food
Photo by Victoria Shes on Unsplash

Severe vitamin D deficiency is endemic from late winter through early spring

Very high levels of vitamin D deficiency were found in all age groups from January to March.

PHE used a remarkably low cut off point for vitamin D deficiency of 25 nmol/L (in the USA this would equate to an eye wateringly low level of 7.2 ng/ml). Very worryingly 19% of primary school children, 37% of secondary school kids, and 29% of adults in the UK study were found to have these devastatingly low vitamin D levels.

Does this mean that everyone else in the study had acceptable vitamin D levels?

Absolutely not!

In Northern Ireland we updated our normal range for vitamin D several years ago so that it is more in line with the American values, where <50 nmol/L is considered a frank deficiency, 50-75 nmol/L is considered insufficient, and those whose blood level is >75 nmol/L are considered to have a sufficient level.

The average vitamin D level for children of all ages was well below 50 nmol/L in January to March, so in Northern Ireland we would consider the average child to be deficient.

The vitamin D level for the top 2.5% of children came back between 58-72 nmol/L. So not even all children in the top 2.5% of vitamin D levels would be considered to have sufficient vitamin D levels in Northern Ireland.

Adults in the top 2.5% of the population for vitamin D levels faired a little better, coming in between 77-84 nmol/L, so at least they could be considered to have sufficient vitamin D levels from January to March.

But the average adult of any age was also rocking a very low level somewhere between about 34 and 43 nmol/L. The average person managed to make it as far as the insufficient range from July to September, if we are going by the standards used by Northern Ireland.

Woman enjoying being outside in nature in the sun
Photo by Fred Mouniguet on Unsplash

But even these numbers may be too low for optimal health

A large meta-analysis of the studies published from 1966 to 2013 showed that vitamin D levels <75 nmol/L may be too low for safety and associated with higher all cause mortality. All-disease mortality was reduced with blood levels of vitamin D ≥100 nmol/L.

In Finland when the recommendation for daily vitamin D supplementation was gradually reduced from 4000-5000 units  pre 1964, to 2000 units a day in 1964, to 1000 units a day in 1975, and finally to 400 units in 1992, the incidence of type 1 diabetes in children aged 1-4 years increased by a staggering 338%, in 5-9 years old it increased by 116%, and in 10-14 year olds by 49%.

The highest incidence rates for type 1 diabetes in Finland were recorded in 2006. In 2003 the Finnish government introduced vitamin D fortification of all dietary milk products with the animal-based vitamin D3 (not the plant-based vitamin D2). Following this type 1 diabetes rates in Finland plateaued, and then actually started to fall again. Coincidence? Who knows, but there is now quite a lot of evidence linking low blood levels of vitamin D with autoimmune conditions in general, such as multiple sclerosis, and not just type 1 diabetes.

What is the optimal amount of vitamin D that we should be taking?

This is another controversial topic, although it was discovered several years ago that current recommended intakes of 600 units per day were miscalculated, and that almost 9000 units/day may be necessary for the majority of the population (or ≥97.5% of us living in cold, dark parts of the world, far away from the equator) to enjoy having a vitamin D blood level of >50 nmol/L.

For some unfathomable reason the UK recommends an even lower intake of vitamin D of 10 mcg/day, which is the equivalent of just 400 units. Apparently our scientific advisory committee calculated this somehow, along with other gems that form the basis of the Eat-Hell Guide following their “review of the evidence”. A part of me wonders whether gremlins got onto their computers at night and changed everything without them noticing.

Take Home Messages

People really do try to follow dietary advice

So to round things up, this recent report shows that people do make an effort to change their dietary habits in line with the advice they hear from Public Health agencies. Although apparently it remains very hard to get large groups of people to eat 5 portions of fruits and vegetables every day.

The food industry is also paying attention to dietary policies

The processed food industry also pay attention. They have largely eliminated industrially manufactured trans fats. They are also trying to reduce sugars added to their products.

Junk food - chips and fast food cheese burgers
Photo by Ashley Green on Unsplash

Is government dietary advice likely to improve our health?

Unfortunately their advice has not brought about improvements in the nation’s health. In fact by following it many more people every year are manifesting nutrient deficiencies.

And rather than recommend people turn to real food sources of those nutrients, found in abundance in high quality animal foods from healthy animals living outdoors in the sunlight (where they can make plenty of vitamin D), including red meat and organs, they are instead recommending using suboptimal forms and doses of supplements which may also be contaminated with the toxic heavy metal lead in the case of calcium. These cheap, low quality, synthetic micronutrients are used to “enrich” or “fortify” the most inflammatory, nutrient depleted foods in our diet (flour and grains).

Is advice to increase fruit and vegetable intake specific enough?

PHE do also suggest increasing intakes of fruits and vegetables, but before you get too excited and start congratulating them on this, they did not specify that these should be unprocessed or minimally processed. In fact pretty much the only reference to processed foods was in the setting of processed meat.

Just let that sink in for a minute: food processing was not touched on for refined carbohydrates, or any other junk food, only for red meat.

PHE has no problems with you eating all the ultra-processed junk food you want, so long as it does not contain red meat, sugar, salt or saturated fat, and it fits within your low fat macros and energy allowances, but they do have a problem with you eating red meat.

Again, this opens the doors for the food industry to provide highly addictive, ultra-processed foods, full of food additives. They want to create shelf-stable, visually appealing (if you like fluorescent, unnaturally coloured products; I hate them myself), ultra-palatable concoctions of fake foods which contain some fruits, vegetables, nuts and seeds, while also being marketed as healthy, according to the standards set by the Eat-Hell Guide.

Recognising clinical nutrient deficiencies is a lost art amongst doctors, and the public

Given that the Eat-Hell Guide has managed to increase people’s risks of nutrient deficiencies, it might have been nice for PHE to create a document that lists signs and symptoms of nutrient deficiencies for both the public and doctors.

You know, useful things like:

  • “if you struggle to drive at night because of glare from headlights, or you go blind at night time, or you seem to pick up far more infections than average, and you rarely or never eat liver, cod liver oil, or eggs, you should have your vitamin A levels checked.” Or
  • “if you are feeling exhausted, run down, and have been putting on a lot of weight recently, are constipated, and you seldom if ever eat seafood, or do not eat a lot of dairy, you should check your blood selenium levels and a spot urine test for iodine, as well as your thyroid function.”

Wouldn't it be NICE if PHE released a handy guide listing top real food sources of nutrients?

A handy guide listing the top real food, unfortified sources of nutrients that are becoming more deficient would have been cool too.

PHE might have learned something from that exercise the fact that;

  • liver is the top or one of the top sources for many nutrients,
  • cod liver is a real food, and it actually tastes great. No, it really does,
  • red meat is really nutritious,
  • shellfish is superb, and
  • fibre is found in loads of foods, and many of them are not even plants

Of course they would also have to realise that mushrooms are fungi, and that fungi have their own kingdom. And that chitin is found in invertebrates as well as fungi. And that there are other indigestible long chain polysaccharides found in the connective tissue of animals that act as prebiotic fibres!

Pan of mushrooms - real food

Same old same old pseudoscientific dietary guidelines

So overall somewhat of a failure to reflect on past nutritional misdeeds and learn from them. And a perpetuation of the same fad low fat diet and largely unscientific junk science that has been served up in the UK since the 1980s at least. I wish I could summon up an iota of shock.

Are you surprised by these results?

Have you been trying to follow conventional dietary advice? Have the pounds been creeping on? Are you feeling tired? Have you been diagnosed with diabetes or prediabetes? Are you suffering from anxiety and depression? Are you feeling burned out? What if the reason you’ve been feeling awful is because of the dietary guidelines? Drop your comments below.

If you have been suffering from any of these problems, this post on how to deal with anxiety gives you plenty of actionable steps that you can use to start feeling better today. It has plenty of suggestions on ways to improve your nutrition, reduce your stress levels, increase your energy levels, boost your metabolism, feel more connected with other people and more, 

And if you’d like some help in reclaiming your health, get in touch.

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