24th February 2012, Volume 125 Number 1350

Jane L Elmslie, J Douglas Sellman, Ria N Schroder, Frances A Carter

Obesity results when energy intake exceeds expenditure. However, the relative importance of the many factors that contribute to energy balance continues to be the subject of considerable debate.1,2 Most researchers and clinicians agree, however, that reduction of energy intake (eating fewer calories/kilojoules) is a vital component of weight management.2,3 Furthermore, humans did not evolve to eat a highly processed diet4 and the benefits of consuming less processed diets, high in naturally occurring micronutrients, such as the Mediterranean diet or that used in the Diabetes Prevention Programme, are very clear.5,6

Advising obese patients to “eat moderately,” “eat a balanced diet,” “reduce fat and sugar” or “eat fewer calories” seems sensible. However, the complexity of the modern food supply and the widespread availability of various types of energy-dense (high calorie) foods, low in essential nutrients, makes it difficult to provide simple, clear information about what and how much to eat. Excessive consumption of such foods reduces overall diet quality, and frequently results in inadequate intakes of essential nutrients, while adding considerably to energy intake.7–10

Many processed foods, for example muesli/granola bars, are marketed as ‘healthy’, but while they may contain fruit and nuts, they are also high in fat and sugar, and are essentially just another form of biscuit/cookie. However, in the public mind, ‘healthy’ is often equated with ‘not fattening.’

In practice, patients frequently believe they will lose weight by replacing a biscuit with a muesli bar or soft [soda, fizzy, carbonated] drink with fruit juice, in effect substituting one energy-dense food for another. They are usually surprised to learn that ‘healthy’ muesli bars can contain almost twice as many calories as one Toffee Pop® [chocolate coated] biscuit.11

Misleading or irrelevant nutritional claims further blur the distinction between healthy and energy-dense, nutritionally-deficient foods. Examples include labelling high sugar foods ‘low fat’ or implying that a food is ‘healthy’ merely because it has some ‘natural’ or ‘organic’ ingredients. Even foods that have received nutritional endorsements such as the Heart Foundation Tick may just be the best options in a category of typically high calorie food products such as oven chips, pies or ice cream. Consumers often do not understand these subtleties.12

Various countries have attempted to make the distinction between nutrient rich, and energy-dense, nutritionally-deficient foods clearer to consumers. The United States (US) Dietary Guidelines distinguish between “discretionary calories” (from saturated fat, added sugars and alcohol) and calories found in foods rich in essential nutrients.13 However, US food manufacturers are not currently required to clearly stipulate the proportion of discretionary calories on food labels, although consumers can derive this information from the food label provided if they are sufficiently numerate and motivated to do so.14,15

Both Food Standards Australia and New Zealand16 and the United Kingdom (UK) Food Standards Agency17 have recommended “Traffic Light”, front of pack labelling for foods to provide clarity over which foods form the basis of a healthy diet. This system uses red, amber or green, front of pack colour coding (traffic lights) to indicate, whether levels of total and saturated fat, sugar and salt are high, medium or low per 100 g/ml. This allows consumers to judge at a glance, the relative dietary merits of the foods they are considering purchasing. Perhaps not surprisingly, the food industry has reacted negatively to this system and is vigorously lobbying governments to prevent its mandatory introduction.18

Currently, New Zealand does not require food to be labelled using this system, although its voluntary introduction has been recommended by a joint Australian and New Zealand review of food labelling law and policy.16 Instead consumers are required to make complex decisions, often requiring a sophisticated understanding of nutrition and food composition to eat healthily. In such a complex landscape, clinicians may struggle to provide patients with meaningful weight control advice and support.

The need for disease-specific dietary education materials for patients with comorbidities such as diabetes and cardiovascular disease can make this task even more difficult. Simple, unambiguous patient education materials may make it easier to provide nutritional messages while at the same time maintaining patients’ motivation to change.

The present paper aims to provide a list of non-essential, energy-dense, nutritionally-deficient foods (NEEDNT foods). This is not simply another list of high calorie foods. This is a list of foods which are usually high in calories and either bereft of nutritional benefits or easily replaced with a lower calorie, more nutritious alternative. It is hoped that this list will be a simple tool to help adult patients differentiate foods required for good health, from those that are non-essential, energy-dense, and nutritionally deficient. It is intended that this list will be used by medical practitioners and other health professionals working with adults who are overweight or obese, who want to lose weight.

Methods

The NEEDNT Food List was compiled using the National Heart Foundation and Diabetes New Zealand “Foods to Avoid”, “Stop Eating” and “Optional Foods” lists,19–21 the Canterbury District Health Board “Supermarket Shopping Guide” 22 and the USDA population guidance on discretionary calories.13 Foods and beverages were included if they contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. As it has no energy value, salt was not a criterion for inclusion on the List.

Results

More than 50 potential foods or groups of foods, such as desserts and takeaway foods were identified that contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. Following discussions with current research patients undergoing obesity treatment and obesity treatment colleagues, the List was finalised as an arrangement of 50 foods/groups of foods. Many of the identified foods are high in salt as well as energy. Tables 1 and 2 show the NEEDNT Food List organised alphabetically and for easy reference, in groups according to potential uses. Suitable alternative foods are provided where possible.

Discussion

The present paper aims to provide clinicians and patients with a clear unambiguous list of non-essential energy-dense, nutritionally-deficient foods. This is not simply another list of high calorie foods. This is a list of foods that are usually high in calories and either bereft of nutritional benefits or easily replaced with lower calorie, more nutritious alternatives. The List is intended as a simple tool to help medical practitioners and other health professionals initiate conversations about food consumption patterns which may promote and maintain obesity and to increase patients’ awareness of the relative energy and nutrient densities of many commonly consumed foods.

The purpose of the NEEDNT Food List is to clearly distinguish empty calorie, nutrient poor foods from which it is possible to safely abstain without adverse nutritional consequences. All foods with high energy density relative to essential nutrient content are included on the NEEDNT Food List. For the most part distinctions between foods that require users to read food labels are avoided but this was not possible in some cases, such as breakfast cereals and crackers. To avoid confusion, the List does not distinguish between “red” and “amber” foods.

Many amber foods are energy-dense and relatively low in essential nutrients, just not to quite the same degree as “red” foods. For example, fruit juice is on the NEEDNT Food List because while it contains more essential nutrients than soft drink, its sugar content is similar; it is easily consumed in large amounts and it is much higher in energy and lower in essential nutrients than whole fruit.

Table 1. Non-essential energy-dense nutritionally-deficient (NEEDNT) foods and their lower calorie replacements
NEEDNT food
Replace with
Alcoholic drinks
Water/diet soft drinks
Biscuits
*
Butter, lard, dripping or similar fat (used as a spread or in baking/cooking etc.)
Lite margarine or similar spread or omit
Cakes
*
Chocolate
*
Coconut cream
Lite coconut milk/coconut-flavoured lite evaporated milk
Condensed milk
*
Cordial
Water/sugar-free cordial
Corn chips
*
Cream (including crème fraiche)
Natural yoghurt (or flavoured yoghurt depending on use)
Crisps (including vegetable crisps)
*
Desserts/puddings
*
Doughnuts
*
Drinking chocolate, Milo® etc.
Cocoa plus artificial sweetener
Energy drinks
Water
Flavoured milk/milkshakes
Trim, calci-trim or lite blue [cap] milk
Fruit tinned in syrup (even lite syrup!)
Fruit tinned in juice/artificially sweetened
Fried food
Boiled, grilled or baked food
Frozen yoghurt
Ordinary yoghurt
Fruit juice (except tomato juice and unsweetened blackcurrant juice)
Fresh fruit (apple, orange, pear etc. + a drink of water)
Glucose
Artificial sweetener
High fat crackers (≥10g fat per 100g)
Lower fat crackers (≤ 10g fat per 100g)
Honey
*
Hot chips
*
Ice cream
*
Jam
*
Marmalade
*
Mayonnaise
Lite dressings/lite mayonnaise
Muesli/granola bars
*
Muffins
*
Nuts roasted in fat or oil
Dry roasted or raw nuts (≤1 handful per day)
Pastries
*
Pies
*
Popcorn with butter or oil
Air popped popcorn
Quiches
Crust-less quiches
Reduced cream
Natural yoghurt
Regular luncheon sausage
Low fat luncheon sausage
Regular powdered drinks (e.g. Raro®)
Water/diet/sugar-free powdered drinks
Regular salami
Low fat salami
Regular sausages
Low fat sausages
Regular soft drinks
Water/diet soft drinks
Rollups
Fresh fruit
Sour cream
Natural yoghurt
Sugar (added to anything including drinks, baking, cooking etc.)
Artificial sweetener
Sweets/lollies
*
Syrups such as golden syrup, treacle, maple syrup
Artificial sweetener
Takeaways
*
Toasted muesli/granola and any other breakfast cereal with ≥15g sugar per 100g cereal
Breakfast cereal with <15g sugar per 100g cereal, >6g fibre per 100g cereal and <5g fat per 100g cereal (or <10g fat per 100g cereal if cereal contains nuts and seeds)
Whole milk
Trim, calci-trim or Lite Blue [cap] milk
Yoghurt-type products with ≥10g sugar per 100g yoghurt
Yoghurt (not more than one a day)
* No suitable alternative.

Whole milk is on the List because while it is a valuable source of essential nutrients (such as calcium and protein) it is also a significant source of energy and saturated fat. It can be easily replaced by low fat milk, which is higher in calcium and protein, without any detrimental effect on overall nutrition, except in the very young. However high calorie unprocessed foods such as plant oils, avocadoes, hard cheeses and dry roasted or unroasted nuts were categorised as nutritious because these foods are valuable sources of essential nutrients despite their relatively high energy content. This categorisation is deliberately different from most “traffic light systems” intended for population dietary guidance, which place nutrient-dense, energy-dense foods such as cheese and plant oil spreads in the amber category because of their high energy and/or saturated fat content.12,23

The NEEDNT Food List is similar to proposed Front of Pack Traffic Light Labelling schemes in that it clearly identifies foods that are high in empty calories and low in essential nutrients. However the List is not intended to give consumers specific information about the relative fat, sugar and salt content of different products in the same way as Front of Pack Traffic Light Labelling or programmes such as ‘Pick the Tick’.24 Instead it provides a clear framework for conversations about eating for weight control that does not require a sophisticated knowledge of nutrition or food composition.

To discourage patients from thinking about their eating in morally judgemental terms such “good” and “bad” or “naughty” without understanding the reasons for these distinctions, categorising foods as healthy or unhealthy has been deliberately avoided and the more accurate and objective terms, energy-dense and non-essential have been used instead to highlight the fact that these foods can be safely avoided without compromising nutritional status, while promoting weight loss.

While we are conscious that simply advising avoidance of NEEDNT foods is unlikely to be an effective obesity treatment strategy on its own, it is increasingly clear that in most western countries such foods constitute a large proportion of the total foods consumed and play an increasingly important role in the maintenance of dietary energy surpluses.25,26 Major social change will be required to reduce the prevalence of obesity at a population level. In the meantime we need to ensure that the available treatment options meet the needs of individual patients.27

We are currently evaluating the utility of the NEEDNT Food List for weight control. The List can help patients become aware of their unnecessary or recreational energy consumption and enable them to prioritise dietary changes accordingly. Recognising the distinction between NEEDNT and nutritious foods can help patients to think about their eating differently. It is envisaged that the List will be given to adults who are obese or overweight, who want to lose weight, and who do not have a current or past history of eating disorders involving restriction and/or binge eating.

Table 2. Non-essential energy-dense nutritionally-deficient foods by group
Foods by group/use
Replace with:
Beverages
Alcoholic drinks
Cordial
Drinking chocolate, Milo® etc.

Energy drinks
Flavoured milk/milkshakes
Fruit juice (except tomato juice and unsweetened blackcurrant juice)
Regular powdered drinks (e.g. Raro®)
Regular soft drinks
Whole Milk

Water/diet soft drinks
Water/Sugar-free cordial
Cocoa plus low fat milk and artificial sweetener/Lite drinking chocolate
Water
Trim, calci-trim or Lite Blue [cap] milk
Fresh fruit (apple, orange, pear etc. + a drink!)

Water/Diet/Sugar-free powdered drinks
Water/Diet soft drinks
Trim, calci-trim or Lite Blue [cap] milk
Biscuits/cakes
Muffins
Muesli bars
*
*
*
Breakfast cereals
Toasted muesli and any other breakfast cereal with ≥15g sugar per 100g cereal
Any breakfast cereal with ≤15g sugar per 100g cereal, ≥ 6g fibre per 100g cereal and ≤5g fat per 100g cereal (or ≤10g fat per 100g cereal if cereal contains nuts and seeds)
Dairy products
Yoghurt type products with ≥10g sugar per 100g yoghurt
Whole Milk

Yoghurt (not more than one a day)

Trim, calci-trim or Lite Blue [cap] milk
Desserts/puddings
Ice cream
Frozen yoghurt
*
*
Ordinary yoghurt
Fats
Butter, lard, dripping or similar hard fat (used as a spread or in baking/cooking etc.)
Coconut cream

Cream (including crème fraiche)

Mayonnaise
Reduced cream
Sour Cream

Lite margarine or similar spread or omit

Lite coconut milk/coconut flavoured lite evaporated milk
Natural yoghurt (or flavoured yoghurt depending on use)
Lite dressings/lite mayonnaise
Natural yoghurt
Natural yoghurt
Fried foods
Doughnuts
Hot chips
Boiled, grilled or baked food
*
*
Fruit
Fruit tinned in syrup (even lite syrup!)
Roll-Ups®

Fruit tinned in juice/artificially sweetened
Fresh fruit
Meats
Regular luncheon sausage (or other processed meat)
Regular salami
Regular sausages

Low fat luncheon sausage (or other processed meat)
Low fat salami
Low fat sausages
Pastries
Pies
Quiches
*
*
Crust-less quiches
Snacks
Corn chips
Crisps (including vegetable crisps)
High fat crackers (≥ 10g fat per 100g)
Nuts roasted in fat or oil
Popcorn with butter or oil

*
*
Lower fat crackers (≤ 10g fat per 100g)
Dry roasted or raw nuts (≤ 1 handful per day)
Air popped popcorn
Sugars/sweets
Chocolate
Condensed milk
Glucose
Honey
Jam
Marmalade
Sugar (added to anything including drinks, baking, cooking etc.)
Sweets/lollies
Syrups such as golden syrup, treacle, maple syrup

*
*
Artificial sweetener
*
*
*
Artificial sweetener

*

*

Takeaways
*
*No suitable alternative.

The List is also suitable for use in patients with cardiovascular disease and diabetes in conjunction with other disease-specific nutrition education information.

Conclusion

Consumption of non-essential energy-dense, nutritionally-deficient foods (NEEDNT foods) undermines patients’ attempts at weight loss, while contributing little in terms of nutrients. Many foods which are marketed as “healthy” are NEEDNT foods. The NEEDNT Food List makes the distinction between nutritious foods and empty calorie foods clear. It is hoped that this List will be a useful tool for medical practitioners and other health professionals working with people wanting to lose weight.

Abstract

Aim

To provide a list of non-essential, energy-dense, nutritionally-deficient foods in New Zealand (NEEDNT foods) which are usually high in calories and either bereft of nutritional benefits or easily replaced with lower calorie, more nutritious alternatives.

Method

The List was compiled using the National Heart Foundation and Diabetes New Zealand “Foods to Avoid”, “Stop Eating” and “Optional Foods” lists and the Canterbury District Health Board “Supermarket Shopping Guide”. Foods and beverages were included if they contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. As it has no energy value, salt was not a criterion for inclusion on the List.

Results

Over 50 potential foods or groups of foods were identified that contained alcohol, saturated fat, added sugar, were prepared using a high fat cooking method or contained a large amount of energy relative to their essential nutrient value. Fifty foods/groups of foods were included on the final list (Table 1).

Conclusion

The NEEDNT Food List will be a useful tool for medical practitioners and other health professionals working with people wanting to lose weight.

Author Information

Jane L Elmslie, Research Fellow/Dietitian1; J Douglas Sellman, Professor of Psychiatry and Addiction Medicine and Director1; Ria N Schroder, Research Fellow1; Frances A Carter, Research Fellow2. 1. National Addiction Centre, Department of Psychological Medicine, University of Otago, Christchurch. 2. Department of Psychological Medicine, University of Otago, Christchurch

Correspondence

Dr Jane Elmslie, Research Fellow/Dietitian, Department of Psychological Medicine, University of Otago – Christchurch, PO Box 4345, Christchurch, New Zealand. Fax: +64 (0)3 3720407

Correspondence Email

jane.elmslie@otago.ac.nz or jane.elmslie@cdhb.govt.nz

Competing Interests

None declared.

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