Dr. Troy Gatcliffe

The prescription is fascinating, sensible and easy to remember – and it might save your life: Shop the perimeter.

The reference is to the grocery store, and Florida’s “Foodie Physician” Dr. Sonali Ruder and Cayman’s Dr. Kalila Bodden agree: The “perimeter” is where the refrigerators and freezers are – stocked with frozen vegetables, milk, yogurt and other dairy products – and where shoppers will find bins of fresh fruit, vegetables and other produce, and where butchers offer clean cuts of meat and just-caught seafood.

As buyers move toward the middle of the store and its long aisles of shelving, the food becomes progressively more processed – and worse for you.

Doritos and potato chips require little supervision, soda rarely goes bad, candy is secure in its wrappers and processed snacks repose comfortably beside school supplies, paper products and cleaning solutions.

“Shop the perimeter means to stock up on the more nutritious ingredients that are typically located around the periphery of the grocery store,“ says New York City-trained nutritionist Ruder, “and [you can] limit the amount of high-calorie, processed foods that tend to occupy the middle aisles.

“The nutritious items you want to stock up on are things like fresh fruits and vegetables from the produce section – and frozen fruits and vegetables from the freezer aisle – and whole grain breads from the bakery, low-fat dairy products like milk, cheese and yogurt from the dairy section, and lean protein including seafood, poultry and eggs from the meat section,” she says.

“An important group of nutritious foods that we shouldn’t forget about that’s not located in the perimeter is the legumes group,” Ruder adds.

“These products, which include beans, peas, chickpeas and lentils, are usually found in the canned or dried bean section and are an important plant-based source of protein, fiber, vitamins and minerals.”

Dr. Sonali Ruder

‘Food for Thought’

Ruder is this year’s keynote speaker at Cayman’s eighth annual healthcare conference, titled “Food for Thought: Exploring the Relationship Between Nutrition and Health,” staged by the Ministry of Health and 40 partners. The conference, which is free and open to the public, is from Oct. 19-21 at The Ritz-Carlton, Grand Cayman.

In a written introduction to the gathering, Cayman Minister of Health Dwayne Seymour said, “‘Food for Thought’ was of particular importance as we seek to explore the relationship between what we eat and how it can affect our health; the benefits of educating the community on making better choices; and taking control of their health and wellness through better nutrition.”

Ruder, of Fort Lauderdale, will drill down, devoting 45 minutes at the evening opening to “Healthy Eating at the Different Stages of Life,” addressing the relationship between nutrition and health through the different stages of life, and will discuss the emerging field of culinary medicine, “which blends the art of food and cooking with the science of medicine.”

Bodden will speak at 10 a.m. Saturday, under the broad rubric of “mental health,” but with a particular focus on “Junk Food: Fun Food or Toxic Temptress?” which, she says, “will differentiate between healthy and pseudo-healthy foods (foods that are marketed as healthy, but are really just junk food in disguise).

“You will also find out how hyper-palatable engineered food compels you to crave it incessantly,” she says.

Bodden, who stays abreast of the ever-emerging medical research supporting the symbiotic relationship between food and health, echoes Ruder’s observations about grocery store structures. “The ultra-processed foods are in the middle … they don’t need refrigeration. Produce and fresh foods are at the edges.”

Citing the U.N. Food and Agriculture Organization’s NOVA food-classification system, Bodden identifies four levels of industrial processing.

Level 1, she says, is natural, fresh and entirely unprocessed, such as bananas, coconuts, cuts of fresh meat from the local butcher, and dairy from the farm.

Level 2 is slightly more processed, she says, but similar to the first category, such as a store-bought chicken that is baked, boiled or grilled for home or even restaurant consumption, with herbs and seasoning.

Level 3 starts to describe processed foods that have two, three and four ingredients, usually from the first two categories, but processed to be more convenient and more packaged, food ready to fry, Bodden says. “You might eat a salad, for example, but soak it in bottled dressing.”

Level 4, however, is where the real trouble starts. “It’s ultra-processed,” the doctor says. “Stuff like Doritos and Pop-Tarts. They are created as ready-to-eat and ready-to drink, designed as replacements for real food.”

Comestibles at this level are “products,” she says, “brands manufactured to “get you to eat their products.

One way to spot them is if they have a TV commercial.

“Look at the label,” Bodden says, pointing to sophisticated packaging. “They imitate the secondary tactile and taste qualities of level 1 foods, and often have artificial sweeteners and colors, bulking and glazing agents.”

A 2014 paper by a quartet of medical researchers says “NOVA has been successfully applied … in Brazil, Chile, Canada and the UK, and to market data from 79 high- and middle-income countries,” indicating that developed nations are among the worst offenders.

“Studies in Canada and the UK using NOVA have shown that ready-to-consume products, and in particular ultra-processed products, have come to dominate dietary patterns in these high-income countries. The most apparent important factor that has driven changes in Canadian dietary patterns between 1938 and 2011 has been replacement of foods and ingredients used in the preparation of dishes and meals, by ready-to-consume products, mostly ultra-processed,” the authors write.

They detail industrial processing as drying, flaking, hydrogenation, hydrolysis, extruding, molding, reshaping and preliminary frying and baking.

And as the processed food industry researches “mouth feel” for its products, Springer describes them as “durable, convenient, accessible, highly or ultra-palatable, often habit-forming and typically, not recognizable as versions of foods.”

An all-too-familiar list

The authors provide a list – lengthy and familiar: cakes, biscuits, breads and breakfast cereals; French fries, burgers and hot dogs; margarines; desserts and “energy” bars; carbonated cola, “energy” and “fruit” drinks; numerous baby products; and “health” or “slimming” products such as powdered or “fortified” meal and dish substitutes – and that’s only partial.

A sure sign of ultra-processed food, Bodden says, is ingredients “you would never have in your kitchen.” Springer names “stabilizers, emulsifiers, solvents, binders, bulkers; sweeteners, sensory enhancers, colors and flavors.”

Read the packages, the doctor intones. “If they say ‘enriched’ or ‘fortified,’ it means the food has been stripped of nutrients and chemically replaced. If it says ‘healthy,’ well, why say it?

“Look for red flags. If something has more than five ingredients, what are they? If a fifth-grader cannot pronounce them, then it’s probably ultra-processed,” she says.

Background

Ruder, whose medical degree sits alongside her certificate from Manhattan’s Institute of Culinary Education, did an emergency medicine residency at St. Luke’s-Roosevelt Hospital Center in Manhattan, followed by an emergency ultrasound fellowship at the Jacobi Medical Center in the Bronx, New York, where she worked for seven years.

“While I was in school, I worked in the ER during the day and attended the [culinary school] at night,” she says. “I loved culinary school. I started my blog, ‘The Foodie Physician,’ while I was a student.” She is currently seeking a nutrition certificate from Tufts University, working online from her Florida home.

Combining her training as doctor and chef, she developed a personalized version of “culinary medicine,” initially taught in 2013 at Tulane University’s medical school.

The objective, she says, is to help patients consume “high-quality meals that help prevent and treat disease and restore well-being.

“As doctors, we can counsel our patients to ‘eat healthier,’ but what does that really mean? If physicians are trained how to make healthier food choices in and out of the kitchen, then they will be better able to counsel their patients about it.”

In the ER, Ruder confronted junk food’s long-term chronic consequences: “The most common ones I encounter are Type 2 diabetes, hypertension, chronic respiratory diseases, heart disease – heart attacks and stroke – and cancer.

“Lifestyle factors such as poor diet, lack of physical activity – kids are on their phones all day now instead of playing outside like they used to – and smoking play a significant role in the development of these diseases.”

Ultra-processing, combining “hidden sodium, sugar, and fat, and sugar-sweetened beverages like soda and energy drinks …” and growing portion sizes in restaurants, means “you can see why obesity and all of the diseases that go along with it are on the rise.”

And that Ruder says, is why one of her “most important healthy-eating tips is to cook at home.”

Cancer link in the Caribbean

The cancer link may top the list of Caribbean fears, according to Troy Gatcliffe, part of the gynecologic oncology team at Miami Cancer Institute at South Florida’s Baptist Health.

He will address the conference at 9:30 a.m. Friday, speaking on “The Big C – The link between diet, obesity and cancer.”

Gatcliffe will tell the conference that research suggests a Western diet, rich in meat, dairy and processed foods, refined sugar, salt and oils, is linked to higher incidences of cancer, although he carefully adds that ongoing studies efforts seek to confirm that.

But, he notes, “The healthiest populations of people around the world, with the lowest rates of our leading cancer killers (lung, colon breast, etc.) eat very little to none of these foods.”

Statistics from the World Cancer Research Fund, he says, indicate “that about 20 percent of all cancers diagnosed in the U.S. are related to body fatness, physical inactivity, excess alcohol consumption and/or poor nutrition.”

Noting that these factors, all related, mean the cancers could also be prevented, Gatcliffe says, “Body weight seems to have the strongest evidence linking it to cancer. Excess body weight contributes to as many as one out of five of all cancer-related deaths.”

Gatcliffe relies on the traditional body mass index developed in the early 19th century by Belgian mathematician Lambert Adolphe Jacques Quetelet. A sort of grid, the BMI plots height against weight, differentiating by gender and making little allowance for proportions of bone, muscle and fat in the body.

Nonetheless, he quotes a 2012 U.S. study using both BMI and cancer-incidence data which estimated that 28,000 new cases of cancer in men and 72,000 in women that year were due to overweight or obesity. Figures from a 2017 American Cancer Society study state that “about 1.1 million new cases and 600,000 cancer deaths are estimated to occur annually” in the Caribbean and Latin America.

Prostate cancer, he says “is the leading cause of cancer death among males, with approximately 51,000 deaths annually, followed by lung and stomach cancer.”

Dr. Kalila Bodden

While mortality also follows long-established patterns of association with economic development, infectious agents and racial/ethnic origin, Gatcliffe cites “obesity and overweight [which] are on the rise throughout Latin America and the Caribbean,” where problems are particularly prevalent among women and children.

Figures from the Food and Agriculture Organization, the Pan-American Health Organization and the World Health Organization indicate close to 360 million people – 58 percent of the region’s inhabitants – are overweight, with the highest rates in the Bahamas (69 percent), Mexico (64 percent) and Chile (63 percent).

‘Alarming’ child obesity rates

Calling them “alarming,” Gatcliffe details childhood obesity rates in the Cayman Islands: “The latest statistics reveal the alarming extent of this problem, and in Cayman alone, one in five children are overweight or obese before they start primary school. By the time they leave, this increases to almost one in three.

“It is therefore essential that we tackle both childhood and adulthood obesity to prevent cancer. As obese children are more likely to grow into obese adults, and obese adults are more likely to develop cancer.”

Echoing the sentiment, Bodden observes that “children grow up with this,” turning into adults, meaning the problem crosses “all demographics.”

Prevention – particularly in less-developed countries – is not simple, relying on half-a-dozen elements: health programs and cancer prevention and screening strategies; feeding research regarding socioeconomic status and current situations. Public education, including anti-smoking and tobacco control, are another weapon, as are awareness campaigns regarding early detection.

“From a dietary perspective,” Gatcliffe says, “education campaigns should also be implemented, highlighting the importance of healthy eating and reducing obesity, within the socioeconomic boundaries (i.e., access to healthy nutrition) of the general population.)”

Conclusions

That dietary perspective forms the “food for thought” conclusions by Bodden, Ruder and Gatcliffe.

“Personal responses can be a challenging pill to swallow,” Bodden concedes, offering five words: “empower, educate and get inspired.”

“If you can make even a 1 percent improvement, you’re winning,” she says, advocating education at home and school, for children and adults, who can pass along habits of “eating from level 1 and level 2.”

It’s simple enough, she says: “Make a personal decision not to eat Pop-Tarts at breakfast and frozen pizza at dinner. It can be transformational when people take responsibility and make changes.”

Gatcliffe says chief among the factors contributing to overweight “has been changes to dietary patterns. Economic growth, increased urbanization, higher average incomes and integration of the region into international markets have reduced the consumption of traditional preparations and increased consumption of ultra-processed products.”

Those traditional preparations tend to include “whole foods” that are cooked slowly and provide nutrients such as fiber, vitamins and minerals with low added sugar and fat.

He holds out hope: “As the population has become more aware of the dangers of processed foods, I believe that there is now a shift back towards ‘traditional foods,’ particularly evident with the emergence of organic farming that does not rely on chemicals, and the farm-to-table practices that are being introduced into restaurants, etc.”

The concept of traditional/whole foods inevitably spills into discussion of traditional diets – rice and fish in Cayman and the Caribbean, the Philippines and Japan; rice and fish or pork in China; rice and legumes in India.

Ruder cites the 2005 National Geographic cover story by Dan Buettner, “The Secrets of a Long Life,” which denotes five “blue zones,” geographic areas where people statistically live the longest: Japan’s Okinawa, Italy’s Sardinia, Costa Rica’s Nicoya, Greece’s Icaria and California’s Loma Linda, home to a significant Seventh-day Adventist community, where residents often live more than 100 years.

“The incidence of diseases like diabetes, heart disease, obesity and cancer in these communities is extremely low,” she says. Author Buettner “found that these communities all shared certain characteristics, including a diet with moderate-calorie intake … of plant-based foods – lots of vegetables, fruit, whole grains, nuts and seeds – and plenty of legumes like beans, peas and lentils, and smaller amounts of meat.”

The populations coupled moderate alcohol consumption with regular physical activity, little smoking, stress reduction, social engagement and commitment to family.

“I believe in moderation. I’m a ‘foodie.’ I love food,” says the “Foodie Physician” with a qualification in culinary medicine. “I think that eating is one of life’s greatest pleasures and I don’t think you should have to deprive yourself. I believe in following a well-balanced, nutritious diet, enjoying the occasional splurge, and leading an active and fulfilling lifestyle.

“I also think that you shouldn’t have to sacrifice flavor when eating healthy food,” Ruder says. “Healthy food can and should be delicious.”

Bodden agrees: “It’s all about moderation.” She calls her talk “actionable,” enabling people to make immediate changes, looking in their kitchen cabinets, reading labels. “People don’t need more doctors” dumping raw data,” she says. “Don’t go ‘cold turkey,’ but keep in mind obesity and hypertension and diabetes. We all have busy lives, but what can we change to make healthy choices? Don’t go to too much of an extreme and cook a four-course meal from the organic farm, but look at ingredients on packages.”

Conference organizers say the entire “Food for Thought” theme is rooted in last year’s gathering, inspired by Dr. Fitzroy Henry’s “Nutrition: The preface to a healthy life.”

Each year, a spokeswoman says, nearly 1,000 attendees receive a post-event survey asking what was of greatest interest and might draw the most attention in the future.

A conference committee. chaired by Health Services Authority chief and CEO of the Cayman Islands Hospital Lizzette Yearwood, supplements its own research, seeking speaker nominations from the medical community and conference sponsors, the spokeswoman said.

“Nutrition was something that stood out in the feedback and is such an important foundation to healthy living that the committee thought it an important focus for more than just a single presentation.”

The theme,” she says, “grew from there to include the range of topics such as food and heart health, diseases triggered by food, fact vs. myth (diets and supplements), food and mental health, food education and nutrition during cancer treatment, on this year’s agenda. 

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