“What The Health”: A Dietitian Weighs In
Nutrition is a controversial and often emotional topic that is widely covered by the media, discussed in films and books, and weighed in on over social media by both experts and self-professed experts alike. Plus, research on nutrition is constantly evolving, and notoriously difficult to conduct and interpret. Findings are often misconstrued when translated for the general public.
With so many competing voices espousing different food and nutrition recommendations, naturally, it can be challenging to sort out fact from fiction.
This has created an environment where the public is confused about what foods are healthy and what they should be eating –and not eating so it’s no wonder that in recent years, diets that restrict major food groups and nutrients have become so trendy, from Paleo and Whole30 on one end of the spectrum to Veganism and Raw Food on the other. We’ve also seen a plethora of explosive documentaries about the food system that suggest “revolutionary” eating approaches to better health. One of the newest films on the scene is the Netflix documentary What the Health advocates for a plant-based diet, seeks to expose the food and pharmaceutical industries, and aggressively questions the nutrition recommendations of major health organizations as well as the American government.
Many health professionals, from physicians and nurses to registered dietitians, have taken it upon themselves to share their perspective on this recent film. Reactions have ranged from outright dismissal of the film as false science wrought with sensationalism and fear-tactics to more nuanced discussions of both pros and cons.
In the Nutrition Matters podcast episode, “What the Health: Review,” three U.S. based registered dietitians, Paige Smathers, Vincci Tsui, and Kathleen Hernder, examine the film’s scientific claims with a critical lens and suggest a more moderate interpretation of its aggressively pro-vegan, anti-industry message.
Andy De Santis RD MPH, a Canadian-based registered dietitian and plant-based diet advocate, also offers a balanced, thoughtful response in his blog post “What The Health?! My Thoughts on the Explosive Anti-Food Industry Documentary.” Andy asserts that while the sensational and polarizing aspects of the film are problematic, its underlying message (eat more plants) is sound.
As a dietitian passionate about helping people make healthier food choices and dedicated to promoting evidence-based nutrition science, I too feel compelled to weigh in. In my opinion, complex topics (and issues surrounding our food and healthcare systems are certainly that) require complex responses. So here goes.
To start, I, like Andy, agree with the film’s underlying message: more plants = better health. Most Americans fall way short on recommended intakes of fruits and vegetables and would benefit from consuming far more.
But MORE plants doesn’t have to mean ONLY plants. The black-or-white approach that the film espouses alienates people. You risk losing the chance to educate and encourage people to make dietary changes that will positively impact their individual health (i.e. increase their intake of veggies, fruits, whole grains, beans/legumes, and nuts) by leading them to believe that the only path to better health is a completely vegan diet.
Furthermore, a plant-based diet that also includes some lean animal-based sources of protein is not only more realistic for most people, but this balanced approach to eating actually offers significant health benefits. Protein from animals is “complete,” meaning it contains all of the essential amino acids, and is superior for building and maintaining muscle tissue, thus preventing age-related declines in muscle mass that lead to slower metabolism and increases in body fat. Protein also plays an important role in satiety, keeping you full between meals (which can help you eat less overall and promote weight management) as well as stabilizing energy and blood glucose levels, and is essential post-exercise for recovery. While you absolutely can get high-quality protein from plants with a well-planned vegan or vegetarian diet, you have to be a lot more conscientious about your foods choices. This brings me to my next point…
A vegan diet is NOT synonymous with a nutritious diet. Oreos are vegan. There are vegan versions of every baked good and processed snack food under the sun. No matter what diet you follow, it is still up to you to make healthy choices. The less restrictive you are, the more opportunity you have to make the best, most nutritious choices from each food group. For example…
For example, not all animal protein is created equal as far as its saturated fat and sodium content, or its impact on your health. There’s a reason registered dietitians promote lean protein sources such as skinless poultry and those containing essential omega-3 fatty acids like fish and seafood. Processed meats such as sausage, bacon, and pepperoni are certainly not health foods; these should be considered treats and consumed occasionally. As the film rightly points out, high intakes of processed and red meat have been linked to increased risk of colon and other cancers. Red meat, poultry skin, and other animal products such as butter tend to be high in saturated fat, which is associated with elevated LDL-cholesterol levels, increasing the risk of heart disease and strokes. This research is on-point and it certainly makes sense to cut back.
However, the film’s spokespeople’s explanation of how fat intake contributes to diabetes is vastly distorted. It disregards the key role of sugar and refined carbohydrates in increasingly widespread chronic conditions such as obesity, diabetes, and heart disease.The film neglects to address how different types of carbs affect the body (fiber-rich, nutrient-dense fruits, vegetables and whole grains versus processed, low-fiber, nutrient-poor soft drinks, cookies, candy, pastries, and snack foods). The film also skirts around the actual science underlying weight gain – energy imbalance. Excess calories lead to weight gain, and while yes, animal products contribute excess calories to many Americans’ diets, foods and beverages high in sugar and refined carbs are a major source of excess calories in the American food system. It's not one or the other that's to blame for high rates of obesity-related chronic disease, but rather a pattern of consuming nutrient-poor, processed foods and a lack of nutrient-dense fresh vegetables, fruits, and other plants.
The film’s flawed explanation of how carbohydrates are metabolized and affect diabetes/obesity is undoubtedly confusing to the general public, in large part because of the medical and scientific-sounding terminology in which it is presented. The same holds true for the vast quantity of research referenced throughout, much of which is questionable and consists of cherry-picked studies chosen to prove a point.
Some of the “science” cited in the film is particularly egregious:
Animal products are responsible for diabetes, not excess intake of refined carbs and sugar. Yes, animal protein tends to be high in saturated fat. But protein itself has no impact on blood glucose and does not trigger an insulin response. Note that the “authority” who was outraged that chicken was being served at a diabetes convention is a comedian! Donuts or soft drinks being served at such a meeting –that might be cause for alarm. But chicken, an excellent source of satiating lean protein, is a fine choice for diabetics as part of a balanced meal.
Over demonization of dairy, including highly exaggerating the saturated fat content of full-fat milk and other dairy products. Even whole milk is only about 4% fat by weight, which is the equivalent to finding 96/4 ground beef. (By comparison, the leanest ground beef typically available in stores is either 80/20 or 90/10.)
Falsely blaming lactose intolerance as a reason to avoid cheese and yogurt. Lactose is the sugar in dairy, and although some people develop an intolerance with age (more commonly in communities of color), there is actually very little lactose in cheese, or Greek yogurt- which is an excellent source of protein, calcium, and probiotics.
Correlation versus causation. The film falls prey to one of the biggest problems in interpreting nutrition research – the tendency to conclude cause and effect from data that actually only shows an association. Also, confirmation bias- once you’re looking to prove a point, you can always find at least one study to support it. And this film is a prime example of that.
Although I don’t agree with the sensationalist approach or extremist view the film takes, there are several larger issues it raises about our healthcare model and food system that are worth pointing out:
Raising animals for consumption on a large-scale is not an environmentally or economically friendly practice.
The funding of nutrition research and health organizations by food companies and groups with a financial stake in Americans’ food consumption (“Big Food” and “Big Ag”) is concerning and lends doubt to research findings and nutrition recommendations.
There is an inherent conflict of interest in the USDA’s dual roles of creating dietary guidelines and also subsidizing the crops such as corn, wheat and soy which make up the majority of the processed foods in our food system – and animal feed.
The influence of food companies and pharmaceutical industry lobbyists on government regulations and guidelines is problematic.
Healthy food access is a major social issue, and socioeconomic disparities are highly correlated with health disparities.
Lack of nutrition training in medical school and the influence/economic power of pharmaceutical companies means that patients are frequently prescribed meds and other treatments for chronic diseases, rather than educated on changes they could be making to their diets.
Finally, there is no real money in the U.S. healthcare system for prevention (i.e. people being able to receive nutrition counseling from a registered dietitian) but there IS coverage for treatment (i.e. medications and procedures to treat chronic diseases that result in large part from controllable factors like diet.) It is backwards, but unlikely to change anytime soon given the financial stake of Big Food, Big Pharma and Big Ag in maintaining the status quo. Though this is certainly not the first documentary to do so, and despite its many flaws, What the Health is an important film for shedding light on this reality, and stirring up controversy, which is a necessary precursor to systemic change.
Bottom line: Diet and lifestyle choices have a big impact on promoting health and preventing disease – far outweighing the role of genetics. Most Americans will benefit from eating more plants, and fewer animal products, particularly red and processed meat. But it’s not a zero-sum game. Balance and moderation are keys to a sustainable, nutritious diet that can be enjoyed long-term as part of a healthy lifestyle.
