Thinking like a dietitian about a carton of soy milk

A very belated Merry Christmas and Happy New Year to you all! After spending two action-packed weeks with my family (and Saturdays volunteering for the community nutrition program where I did my placement), then catching up on my sleep and my work, I'm finally ready to get back to blogging.

I originally started this entry wondering how "perfect" dietitians need to be. Of course I know we're not perfect—I've hung out with enough current and future dietitians to know that we buy lunch from the cafeteria, hold Christmas parties complete with cupcakes and cookies, share plates of fried noodles and fried rice at our local cha chaan teng, and make drool-worthy cinnamon buns complete with cream cheese icing.

What I mean is, how "perfect" does our advice need to be? Should we only recommend plain yogurt, unsweetened cereals, and steamed vegetables? Should we always condemn fruit juice as a fruit serving, or white bread/rice?

This thought first came to me at the Christmas party we held (see photo) as part of a series of workshops geared toward low-income families with kids aged 4-10. Usually this workshop was just a regular "cooking class", but because it was around Christmas, we were able to add a few more recipes, put on some Christmas carols, and attract more participants.

Compared to the usual chips, chocolate and cake that you can usually find at a Christmas party, the snacks that we had were healthy. We had rice balls with a bit of "red rice" (a type of brown rice) added in for extra fibre and filled with canned tuna, salad in tomato cups (with low-fat, non-flavoured yogurt in place of the usual Miracle Whip/mayo with condensed milk "salad dressing" found in Hong Kong salads), tuna fish paninis with low-fat cheese, mini-pizzas, and fruit-yogurt-cereal parfaits.

Sure you could nitpick that a lot of our ingredients were processed—canned tuna, frozen imitation crab meat, and kernel corn from a carton are a few examples; the only fresh ingredients we used were the fruit for the yogurt parfait, and tomatoes. We used a fairly sweet cereal in our yogurt parfaits, processed cheese slices for our sandwiches and "pizza", and like I mentioned before, you'd be hard pressed to find a good whole grain bread here in Hong Kong. If good whole wheat bread is hard to find, then pita bread or tortillas are harder, so we were forced to use regular bread for our "mini-pizzas" and ketchup, since the volunteer we sent out to do the groceries couldn't find tomato sauce in the store. (Though on a subsequent trip I spotted it quite easily, and like the kernel corn, it came in a box.) However, given our resources (cost and facilities) and the availability of certain foods, I'd say we did a pretty good job.

What irked me the most though, was the praise that the dietitians I work with heaped on Calci-Plus. Calci-Plus is a calcium-fortified soy milk, which is actually not that common in Hong Kong/Asia, because soy milk was developed way back in the day as its own beverage, unlike the West, where its gained popularity in recent years as a dairy replacement. At first, I couldn't help but cringe at the fact that its vague nutrition label (allowed to be so until the legislation becomes effective in 2010) shows that each cup contains "up to" 2½ tsps of sugar.

But then I realized that even though it has added sugar, the bigger questions are whether it is a suitable substitute for milk and whether it is really that much better than other soy beverages out there. Of course, this is really hard to do with the limited nutrition info available—the carton doesn't list the calories, nor does it list the total carbohydrates and protein so that you can calculate the calories.

From a calcium standpoint, it looks like Calci-Plus contains levels that are equal to or higher than milk. Additionally, vitamin A & D fortification is not mandatory here, so that is not an issue. We might have to wait till 2010 to reach a verdict, but if drinking Calci-Plus instead of milk doesn't add extra calories, doesn't take away from the amount of protein, etc, then I think it's ok if you're not a milk-drinker... and I'm ignoring the whole issue of isoflavones here.

In terms of other soy milks, the "perfect" recommendation would be unsweetened, calcium-fortified soy milk. I have seen imports like SoGood or SoNice in stores here, but they're generally more expensive than locally produced soy milks (and might not even be available in the low-income community we were working in), and I've found that they don't have the same "soy" flavour that Chinese soy milks do.

Compared to the different soy milks I've seen in Hong Kong, Calci-Plus does not have the lowest amount of added sugar, but it should be noted that "regular" sweetened soy milk tends to have almost double the amount. That's right, over 1 TABLESPOON per cup. While they may not all be fortified with calcium, the various add-ins (like my favourite, black sesame) and amounts of these add-ins make it hard to judge which one is best.

Aside from just looking at the nutrients though, I hope you've noticed that I've mentioned some non-nutritional factors affecting food choice. Because what good is a healthy food if someone can't find it, can't afford it, doesn't have the means to prepare it, or doesn't like the taste?

Now coming full circle to my first question of how "perfect" dietitians should be, I think it depends on the audience. In individual counselling, the dietitian is more knowledgeable about the client's current diet, so I think you can work in baby steps instead of making huge changes right away in order to increase the feelings of success and compliance. For example, my dad eats a fruit-flavoured yogurt in front of the TV every evening. While I've told him many times that plain yogurt would be better, especially with his diabetes, he keeps on buying fruit-flavoured yogurt. Looking at the big picture, fruit-flavoured yogurt is probably fine because if it weren't for this yogurt cup, my dad wouldn't get any dairy at all, so this is better than nothing (but of course, the occasional nudge toward plain yogurt doesn't hurt either!)

I think it's more important to be strict when you're dealing with groups or the community at large because many people already have healthy habits to begin with, and you don't want to mislead them into "stepping down". It's really easy for people to read one article or hear one opinion on a certain food and swear it off forever or eat tons of it, especially if they have really strong feelings for or against the food to begin with. For example, you don't want milk drinkers to suddenly switch to chocolate milk because it's "just as nutritious as white milk", but if you're working with a kid who isn't getting any dairy to begin with, chocolate milk might be a place to start.

There is a trick to optimal nutrition, and that trick is eating a balanced diet. The problem is, there is no clear definition of what a balanced diet is, and a diet that's right for one person may not be right for another, for reasons that may or may not be nutritionally related. And that, my friends, is the Dietitian's Dilemma.