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

By Dr Catriona Walsh
In January 2019 the most recent National Diet and Nutrition Survey for the UK was reported on. 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 actually a good idea for anyone of any age to do. 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 found particularly in classic foods as full fat dairy products and from animals 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 as though people are getting the message that fruit juices are high in sugar and very low in nutrients). People living 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 sort of evidence linking unprocessed red meat with adverse health outcomes, and reducing intakes of it 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?

Changes in micronutrients over the 9 year period

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

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, and whose requirements increase during those periods as well.

For example vitamin A intake has been falling in all age groups, but adolescent girls have particularly poor intakes. 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 (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.

Folates are also 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). Natural, active folates are found in liver, legumes and leafy greens, 3 foods which are not necessarily high on many people's favourite list. 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.

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.

Blood tests suggested that riboflavin 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.

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.

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 recommendations 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 we who live 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

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 processed food industry also pay attention, and have got rid of industrially manufactured trans fats, and are also trying to reduce sugars added to their products. Unfortunately that 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). 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 of 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 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 in order 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.

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."

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; like the fact that liver is the top or one of the top sources for many nutrients, red meat is really nutritious, and shellfish is superb, and that fibre is found in loads of foods and many of them are not even plants (of course you 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 for this to be true)!

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.

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