Is “MyPlate” Right for You? Creating a New Discourse on the One-Size-Fits-All Approach to Nutrition
America’s obesity epidemic is getting renewed publicity after HBO aired Weight of the Nation in May 2012. A partnership among the Institute of Medicine (IOM), Centers for Disease Control and Prevention (CDC), and National Institutes of Health (NIH), the goal of Weight of the Nation is to bring attention to the obesity epidemic, its causes and consequences, and provide recommendations for its prevention (IOM 2012). However, I believe the recommendations this project gives for the prevention of obesity and chronic disease will not work, especially for Hispanic and Native American communities.
I had been trying to follow similar recommendations—eating fewer calories and exercising more—to those given in Weight of the Nation, whose recommendations are similar to the more familiar “MyPlate” recommendations based on the 2010 Dietary Guidelines for Americans (USDA 2010a, 2010b, 2012). The Dietary Guidelines for Americans (DGA) were developed in 1980 by the U.S. Department of Agriculture (USDA) to help “most Americans” (not applicable to those with chronic diseases that required special diets) manage weight and prevent chronic disease (USDA 1980).
Before MyPlate, MyPyramid was used to graphically represent the recommendations. Food pyramids were also developed for special audiences, including Hispanic and Native American communities. In 1996, Oldways Preservation Trust developed the Latin American Food Pyramid based upon traditional sources of carbohydrates such as corn, potatoes, peanuts, and beans.
Initially, there was concern about the increase in prevalence of coronary heart disease, which was widely believed to be associated with saturated fat intake and cholesterol. As a result, the recommendations were to decrease saturated fat intake, and these calories were usually replaced with carbohydrates. (It may look like the plate is not proportionately higher in carbohydrates, but vegetables and fruit are mostly carbohydrate. And fat is left off the plate.) Most days I ate whole-grain, low-sugar cereal with low-fat milk and a banana for breakfast; salads with cheese, olive oil, and balsamic vinegar dressing, and whole-grain bread for lunch; and whole-grain pasta with low-fat cheese or lentils and rice for dinner. I was also running regularly and had just completed the Orange County Half Marathon and the Los Angeles Marathon.
A Surprising Diagnosis
But I was suffering from anxiety. My main symptoms included tight chest, headaches, and difficulty concentrating due to shallow breathing. At first I thought it was due to graduate school—but I realized that it was physical, not mental, after I began my postdoc and the symptoms were getting worse. In May 2011, I was referred to Dr. Georgia Ede, a psychiatrist at Harvard University Health Services who specializes in nutrition as an alternative to medication. She diagnosed me with “carbohydrate sensitivity,” a term commonly used to describe an exaggerated response to dietary carbohydrates.
In people with carbohydrate sensitivity, carbohydrates cause blood sugar to spike. Insulin, which is released to keep blood sugar from rising to unhealthy levels, also spikes. Finally, adrenaline and other hormones rush in to prevent blood sugar from plummeting to dangerously low levels. Adrenaline is our fight-or-flight hormone—so this explained why my major symptom was anxiety. When adrenaline rushes in it can also overcompensate and cause hypoglycemia, or low blood sugar. I often had the typical symptoms of hypoglycemia, including hunger shortly after meals, irritability, shakiness, sweating, headaches, and difficulty concentrating.
Additional symptoms of carbohydrate sensitivity include sleepiness after eating a high-carbohydrate snack or meal; waking up hungry in the middle of the night; and high appetite and cravings for carbohydrate-rich foods. Physical activity can exacerbate the symptoms because it affects blood sugar and stimulates adrenaline release. The symptoms can be alleviated by reducing dietary carbohydrates, particularly refined and high glycemic index carbohydrates. Since decreasing carbohydrates (the calories of which were replaced by protein and fat) in my diet—the exact opposite of recommendations in Weight of the Nation—my symptoms have disappeared.
Hispanic and Native American Communities Respond Differently to Carbohydrates
Carbohydrate sensitivity is most likely tied to my Mexican American background, and family history of diseases associated with insulin resistance such as polycystic ovary syndrome (PCOS) and type 2 diabetes. My younger sister was diagnosed with PCOS two years ago, and my mother and grandmother, along with several aunts and uncles, have type 2 diabetes. There is no consensus yet among scientists and physicians about the relationship between carbohydrate sensitivity and insulin resistance, and diseases associated with insulin resistance, but Dr. Ede believes that these conditions lie on a continuum and represent different stages along the way to chronic disease. Carbohydrate sensitivity may eventually lead to insulin resistance, which is characterized by release of excess levels of insulin, or hyperinsulinemia, and is associated with a variety of diseases, including PCOS and diabetes. I was possibly heading down the road to developing these conditions.
My story is not unique. Hispanic and Native American communities have historically had higher rates of obesity and diabetes, most likely due to a nutrition transition from traditional to Western diets. But overweight and obesity rates have also increased since the 1980s, and they remain greater in Mexican Americans compared to non-Hispanic whites (CDC 2011; Fryar et al. 2012). The rates of diagnosed diabetes have also increased and are currently greater in Hispanic and Native American communities compared to non-Hispanic whites (CDC 2011; Fryar et al. 2012). Among Hispanics, Mexican Americans and Puerto Ricans have the highest rates of diagnosed diabetes (CDC 2011).
Research shows that Hispanic and Native American communities exhibit differential responses to carbohydrates. Hispanics (most research has focused on Mexican Americans) have higher fasting insulin, decreased insulin sensitivity and clearance (i.e., greater insulin resistance), and higher insulin secretion compared to non-Hispanic whites (Haffner et al. 1992). The Pima Indians have been the focus of considerable research on the mechanisms behind the onset of diabetes because they have the world’s highest rates (Knowler et al. 1978). Compared to non-Hispanic whites, the Pima are also more insulin resistant and produce a greater insulin response to carbohydrates (Lillioja et al. 1991, 1993).
African Americans also have a higher insulin response (Osei and Schuster 1994) and differential expression of genes involved in carbohydrate metabolism (Schisler et al. 2009). Those who follow conventional nutrition recommendations more closely have a higher rate of obesity and insulin resistance compared to those who don’t and non-Hispanic whites (Zamora et al. 2010, 2011).
Additional evidence suggests the same may be true for Hispanic communities. Although the 2010 Report on the Dietary Guidelines for Americans stated that Americans are not following the guidelines, it appears as though the increase in prevalence of overweight and obesity and type 2 diabetes in Hispanic populations (data was analyzed only for Mexican Americans) is because many of us are following the guidelines. Caloric intake has increased but the percentage of calories from saturated and total fat has decreased (Fryar et al. 2012). There has also been a slight decrease in the percentage of calories from protein (Fryar et al. 2012). Instead, the major change in nutrient intake is due to an increase in the percentage of calories from carbohydrates (Fryar et al. 2012). Thus, recommendation of a diet proportionately higher in carbohydrates for the prevention of obesity and insulin-related diseases may be inappropriate for Hispanic and Native American communities.
To be sure, nutrition recommendations are important because they form the basis for food and nutrition policy, which is central to providing access to healthy foods. But they should be based on all of the available science (Hite et al. 2010; Hoenselaar 2012). And, in their current form, they limit access to foods that may be healthy to certain populations.
Carbohydrate Reduction Should Be Considered as Weight Loss Treatment for Diabetic Hispanics and Native Americans
Because obesity is typically associated with type 2 diabetes, the main recommendation by the American Diabetes Association (ADA) for management of type 2 diabetes is weight loss through calorie restriction (American Diabetes Association 2008, 2011). Because fat has more calories than carbohydrates, fat calories are usually replaced by carbohydrates. But low-carbohydrate diets work just as well or better than low-fat diets for weight loss (Accurso et al. 2008 and Hite et al. 2011 for review).
More importantly, low-carbohydrate diets also have a more favorable outcome on serum triglyceride and high-density lipoprotein (HDL), the “good cholesterol” (Accurso et al. 2008 and Hite et al. 2011 for review), which are both better indicators of heart disease risk than LDL or total cholesterol (Hite et al. 2010; Hoenselaar 2012).
In fact, research by Moises Torres-Gonzalez demonstrated this: when overweight men on a carbohydrate-restricted diet consumed more eggs, the increase in dietary cholesterol had a favorable outcome on HDL (Mutungi et al. 2008). Finally, a recent meta-analysis by Harvard scientists suggests that long-term saturated fat intake (the main concern with being on a low-carbohydrate diet) is not correlated with (Siri-Tarino et al. 2010a), while replacing saturated fat with carbohydrates is correlated with, coronary heart disease, cardiovascular disease, or stroke (Siri-Tarino et al. 2010b).
However, these studies have not taken ethnicity into account. Many traditional diets were lower in carbohydrates (Szathmary 1989; Kattelmann et al. 2009). Research by Gary P. Nabhan has shown that plasma glucose and insulin responses to traditional meals are low (Brand et al. 1990).
The only study I am aware of that focused on Hispanic or Native American communities was documented in My Big Fat Diet. Members of the Namgis First Nation of Alert Bay, off the coast of Vancouver Island, gave up sugar and junk food for a traditional diet high in fat and low in carbohydrates. In participants who completed the study there were significant improvements in weight, HDL, and triglycerides (J. Wortman pers. comm.). Given their differential response to carbohydrates, I believe that low-carbohydrate diets would be more effective than low-fat diets for weight loss and management of type 2 diabetes in Hispanic and Native Americans.
Hope for Creating a New Discourse on Nutrition
My hope for this article is that it will inspire an unconventional discourse within the SACNAS community about the causes of obesity and insulin-related diseases and their solutions in our own lives, families, and communities. I also hope it provides relief for those SACNAS members who have tried to eat “healthy,” either because they have undiagnosable symptoms like I did, or were diagnosed with a chronic disease and the recommendations haven’t worked.
I hope it will inspire SACNAS members to pursue research to fill the gaps in knowledge about nutrition and its effects on Hispanic and Native American communities. These studies must be culturally sensitive and appropriate. This is especially true for Native Americans, who have historically been targets of unethical research practices. SACNAS has an emerging partnership with the Native American Research Centers for Health, which has started an initiative to increase funding for community-based participatory research (CBPR).
CBPR is culturally sensitive by focusing on community at all stages, such as involving community members in decision-making and education, and incorporating culturally sensitive practices during meetings (Wallerstein and Duran 2010). For example, the Santa Clara Valley Community Action Project formed an advisory committee made up of community members, advertised a course at community events, began meetings with food and socializing, included prayer, and ended meetings with smudging. As a result, they had the greatest retention and social networks afterward (Jernigan 2010). Participants in a special education course employing a “Medicine Wheel,” a more culturally appropriate approach than dietary guidelines, lost weight and lowered their BMI compared to those getting their usual care (Kattelmann et al. 2009).
Finally, while we wait for the results of these studies to emerge, I believe the DGA should shift away from a one-size-fits-all approach to Elisa Maldonado, PhD nutrition. Given the unique combination of our scientific backgrounds and personal experiences, there is a huge need for SACNAS members to represent our communities and make these changes in food and nutrition policy. The 1980 DGA document rightfully stated, “We don’t know enough about nutrition to identify an ‘ideal’ diet for each individual. People differ—and their food needs vary depending on age, sex, body size, physical activity, and other conditions such as pregnancy and illness.” The guidelines go on to say, “Health depends on many things including heredity, lifestyle, personality traits, mental health and attitudes, and environment, in addition to diet,” (USDA 1980). There is even more evidence these days to support these statements. I have become so passionate about this that after my fellowship is over, I have decided to forego pursuing an academic career in marine biology and transition into lab manager for my laboratory at Harvard, which will enable me to take courses in the School of Public Health. I don’t know what the future will hold, but armed with recommendations that actually work for my and my family’s health and happiness, I’m not so anxious about the future anymore.
Columbia University Summer Public Health Scholars Program
Contact: Daniel Carrion
Diversity Summer Internship at Johns Hopkins Bloomberg School of Public Health
Contact: Jessica Harrington
*The Johns Hopkins Bloomberg School of Public Health has a Center for American Indian Health, with several members actively involved in SACNAS.
University of North Carolina, Chapel Hill School of Medicine - Postdoctoral Fellowship Program in Integrative Medicine
*PIM is conducting clinical trials on the effects of certain foods and diets on physical and mental health, and have a strong commitment to serving underrepresented populations.
University of Connecticut, Neag School of Education, Department of Kinesiology
Contact: Jeff S. Volek, Associate Professor
About the Author
Dr. Elisa Maldonado is a National Science Foundation Minority Postdoctoral Fellow in Marine Biology at Harvard University. After a recent medical diagnosis, she became interested in the effects of nutrition on physical and mental health.
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