Questionable Measures

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Last month, one of my friends told me that his health insurance, Tufts Health Plan, offers Good Measures, a nutrition and exercise tracking website, for free to members like him. When I told him I had never heard of the site, he gave me his login information so I could check it out.

This piece you are reading is by no means a thorough critique of Good Measures, nor do I think a comprehensive evaluation is even necessary, for I have enough concerns from my limited exploration to know that I would not recommend this site to patients.

Having said that, to be fair, Good Measures does have some nice features. My friend, who is a software programmer and artist, was impressed by the site’s visual appeal and how user-friendly it is to navigate and input data. One feature that quickly caught my attention is that if it detects that a user’s intake of a particular nutrient is low, it will go through the person’s food logs and highlight the foods with high concentrations of the nutrient in question in order to show the user that they can increase their intake simply by consuming more of these foods they already eat. Good Measures also presents some new foods for the user’s consideration, which can help to inspire ideas.

My concerns about the website are less to do with its design or mechanics and more about the problematic messages it teaches about nutrition. Even though I do like how Good Measures helps to generate ideas for consuming more of a given nutrient, users are misled into believing that underconsumption is definitively a problem when in fact it might not be at all.

Someone can consume less of a particular nutrient than their estimated needs would call for and often be just fine, but Good Measures teaches quite the opposite by labeling such shortfalls as “under and it matters.” Implying that someone has to hit their target intakes every single day or risk malnutrition creates unnecessary stress and is ultimately misleading because that simply is not how our bodies work.

Deficiencies, which can often be detected through blood analyses, can develop over time if intake of a particular nutrient is chronically low, but they do not suddenly appear after a single day, or even a few days, of consuming below one’s estimated needs.

Part of having a healthy relationship with food is being flexible and varied in our eating. We will be hungrier and eat more on some days than others. Our intake of a particular nutrient could be quite high one day and quite low the next, and that is perfectly fine. In the big picture, our bodies get what they need even if each day is a bit different.

Getting down into the nitty-gritty, another problem I have with how Good Measures addresses issues of nutrient deficiencies and excesses is that it does not take absorption into account. Commonly, we think of putting food “in” our bodies when we eat it, but technically speaking, the food is not actually inside our systems until it has been digested and absorbed through the lining of our gastrointestinal tract.

Various factors influence the fraction of consumed nutrients that make their way into our bodies. Some of these factors are unique to us, such as our genetics and gut microbial populations, but examples of others include food sources and combinations. Good Measures could not possibly take the former into account, and it seems to make no attempt to factor in the latter either.

Consider iron and its two forms, heme and non-heme. Our bodies are quite poor at absorbing iron, but heme iron, which is found in animal flesh, is better absorbed than non-heme iron, which comes from plants. If I eat a piece of steak or a pile of beans with equal iron contents, my body will absorb more iron from the meat than from the legumes. Poor absorption of non-heme iron is why vegetarians are often advised to consume more iron than omnivores, but Good Measures does not seem to account for this. Taking in an iron-containing food with a source of vitamin C, such as a glass of orange juice or some red pepper slices, will improve iron absorption, but Good Measures does not seem to factor in this physiology either.

That such important nuance was overlooked does not surprise me, as my impression is that this website was purposely designed to be overly simplistic. Consider the Good Measures Index (GMI), the definition of which is, well, I will let the website’s help directory explain it.

In my opinion, one of the most significant problems in how our culture views food and nutrition is that we oversimplify and overgeneralize multifaceted issues to the point where our distillations teeter on the border of doing more harm than good, and sometimes they cross right over that line. Given how complex our bodies and our relationships with food are, the notion that our eating can be boiled down into a numeric value strikes me as dubious at best. 

Beyond that, while the GMI seems designed to suggest that there are no good/bad foods, its impact is quite the opposite. Using my friend’s Good Measures profile as a testing ground and various real-life binge incidents that patients have reported to me, I experimented to see how an evening of overconsumption would affect my friend’s GMI. The most severe of the three binge episodes that I tested was enough to plummet his day’s GMI from 94 all the way to zero, which is ridiculous on multiple fronts.

The binge foods that I used in the example, even if they were consumed in excess, provided an abundance of nutrients that the body would utilize to function. To suggest that a binge can negate everything that came before it is nonsense. Reducing the day’s GMI to zero tells the user that positive eating experiences that may have occurred earlier in the day can be undone, which is false and hearkens back to the problematic calories-in vs. calories-out model in which someone’s exercise bout can be viewed as cancelled out if they take in “too many” calories afterwards.

The GMI’s 0-100 scale is similar enough to academic grading to suggest that 100 is perfection, a target for which to strive, and that a score less than that is due to errors, like wrong answers on an exam. In reality, a 100 GMI could indicate that someone is too rigid and might be struggling with orthorexia. Even my friend, whose relationship with food strikes me as quite healthy, felt like his 94 GMI must indicate that he is doing something wrong and wondered out loud if he should be striving for 100. In my practice, I have seen so many eating disorders that were sparked when a high achiever with perfectionist tendencies applied these traits to their eating, and I can easily imagine the GMI furthering this problem.

Another area where Good Measures takes a complex topic and dumbs it down to useless numbers is weight control. Pursuing weight loss is dangerous and problematic for the reasons we discuss here, yet Good Measures acts as if it is just a matter of elementary school arithmetic. Input your age, gender, height, current weight, activity level, and desired weight, and it outputs “your personalized daily calorie goal.”

Earlier in my career, I also used algorithms like theirs to advise people on weight loss. In the long run, they do not work. The calories-in vs. calories-out energy balance paradigm is an oversimplification of the factors that influence weight regulation, which is mostly out of our control.

Consider atypical anorexia nervosa, a condition with all of the restrictive features of anorexia, but the patient is not medically “underweight” despite their severe malnutrition. In other words, atypical anorexia nervosa is, as some of our colleagues say, anorexia nervosa without the weight stigma. Good Measures and other nutrition and fitness trackers can present all the “success stories” they want, but the truth remains that sometimes – oftentimes – our bodies just do not lose weight in accordance with what simple math would predict.

At the other end of the spectrum, weight gain is no guarantee either despite Good Measures also suggesting that putting on mass is just a matter of taking in enough calories. One of my best friends is very thin and wanted to put on weight for aesthetic reasons. He has a PhD in physics, understands energy balance as well as anybody out there, and explained to me that all he has to do to gain weight is take in more calories than he expends. The human body is more complex than that, I cautioned him, but he insisted. Over the ensuing weeks, he increased his caloric intake, logged everything he ate, and tracked his weight on an Excel spreadsheet. One day, he emailed me his spreadsheet and a message saying, “WTF?” While he had gained a small amount of weight, his spreadsheet showed that his weight had leveled off and would no longer budge no matter how many calories he ate. Changing our weight in either direction is just not nearly as straightforward as Good Measures makes it seem.

Tufts Health Plan members who use Good Measures also receive at least one free telephone consult with a registered dietitian, so in fairness, it is possible that the professional on the other end of the line might help to clarify some of the website’s limitations and put the data into better context. However, the soonest appointment my friend could get for his initial consult will not take place until nearly two months after he started using Good Measures. If that is a typical wait time, that means users have approximately eight weeks to misinterpret and internalize whatever they glean from the site.

For nearly two months, people who have an active eating disorder, a history of one, or are at elevated risk for such a disorder are using a triggering tool that can start a downward spiral without first being informed of the risks. According to one estimate, 14.3% of males and 19.7% of females will experience an eating disorder by the age of 40, which loosely translates to one in six individuals overall. Given such high prevalence, Tufts Health Plan is negligent in offering Good Measures to its members without guarding against the harm it does to this segment of the population.

Despite having some nice features and an aesthetically pleasing design, Good Measures has fundamental issues that prevent me from recommending it to patients.