Monday, April 7, 2014

Do vegetarians have poorer health?

I spend a lot of time, probably more than I should, skulking around in nutrition related forums where people share the successes and failures they've had with various weight loss plans and/or change of eating habits for a variety of health conditions.  If someone has had good success with one way of eating, chances are they will talk smack about other plans that are in opposition to their way of eating, and sometimes the points they are making are evidence based, sometimes they are not.  The last blog post I did was based on an article that a vegan friend was using to try to talk people out of their "paleo" diet; now it looks like the more omnivorous types could potentially fire back after reading an article like this one: Study: Vegetarians Less Healthy, Lower Quality of Life than Meat Eaters.  So do they have any evidence to truly turn the tables?  Let's apply the same Double X Double-Take to this news article.

1) Skip the Headline. Step away from the Appeal to Emotion Fallacy.

2) What is the Basis of the Article? This one was easy, click on the link in the article and ta-da!  Looks like we have access to the full article!  Now you get to read it, I'll wait.....
Did you see the "lots of people, lots of data, lots of analysis" to indicate that this is original research that has undergone a peer review.

3) Look at the words in the article.  You did read the article?  All the way through?  Including the part that has "limitations" printed in bold?  Here, I'll help:
"Potential limitations of our results are due to the fact that the survey was based on cross-sectional data.  Therefore, no statements can be made whether the poorer health in vegetarians in our study is caused by their dietary habits or if they consume this form of diet due to their poorer health status. We cannot state whether a causal relationship exists, but describe ascertained associations. Moreover, we cannot give any information regarding the long-term consequences of consuming a special diet nor concerning mortality rates. Thus, further longitudinal studies will be required to substantiate our results. Further limitations include the measurement of dietary habits as a self-reported variable and the fact that subjects were asked how they would describe their eating behavior, with giving them a clear definition of the various dietary habit groups." (Emphasis mine).
In other words, based on the people sampled we can't necessarily extrapolate to the larger population, correlation does not equal causation, we need more studies, and we can't rely of people's memory and subjective description of what they ate to determine treatment. 

4) Look at the original source of the information. As I said before, you will want to ensure that the journal and the article are peer reviewed and not just commentary by an "expert." Experts are human and can be prone to some not so scientific idea.  In this particular case a Google search about the journal indicates it is peer reviewed.

5) Remember that every single person involved in what you're reading has a dog in the hunt.  Once again, be careful that your speculations about what dog is in the hunt doesn't devolve into a variation of the ad hominem fallacy, so hold off on the inflammatory language for a bit.

6) Ask a scientist. Once again, I'm so glad you asked!  Some other points to ponder:
1) This study was done in Austria, and the news article was geared to people living in the United States.  Just because the majority of people in each country speak English doesn't mean they have the same eating habits and access to food. A typical vegetarian diet in Austria is likely different than in the US, I personally would have to research that more so I'm not going on assumptions.
2)  As it states above, we don't know if the vegetarians in this group were already in poor health before they changed their diet.  I can remember doing a rotation on the oncology ward as an intern and seeing people that were trying a variety of different diets, vegetarian and otherwise in the hopes that they would be able to cure their cancer.  Perhaps some of these people were having similar struggles with their physical and/or mental health and were making dietary changes that they thought might help.
3) The term vegetarian and vegan mean that you eschew animal flesh and all animal products respectively, these terms actually don't say anything about the quality of a person's diet.  As one friend of mine said about her husband, "He's more of a "sugartarian" than anything else..."  So perhaps these vegetarians weren't actually eating vegetables and were surviving on rice and chocolate and we can't extrapolate their data to a greater population of vegans who spend time planning their meals to include vegetables, soaking their beans to extract more nutrition, etc.  And before some of you start sputtering about how "that's not a vegetarian diet" you might want to study up on the No True Scotsman fallacy.  And remember, you can take just about any eating plan and make it unhealthy (I'm looking at you, people who survive on Atkins company diet products!)

So what do we do with this information?
1) Don't smoke (sound familiar?).
2) Moderate alcohol intake.
3) Include lots of vegetables and some fruit.
4) Don't over or under do your protein intake.

Edited to correct Australia to Austria thanks to alert reader Eve.  My spell-check needs spell-check.

Monday, March 17, 2014

Smoking Meat?

One of the fun parts about blogging is trying to think up catchy titles for blog posts, particularly since "news" writers get to think up scary sounding titles like Diet High in Meat and Cheese Can Be Bad as Smoking and The Scary News about the Paleo Diet.  Of course, since my sense of humor runs toward the teenage variety, that first title make me think of someone lighting up a sausage and smoking it like a cigarette, hence my title.  (I was probably the only one who thought was funny, unless you are also twelve years old).  So, if you thought I was going to talk about various culinary techniques, thanks for reading so far, but I'm actually going to be talking about whether or not we should be as fearful of eating animal protein as these articles imply.

I think this calls for a review of Emily Willingham's excellent post on how to read science and medical news over at Double X Science: Science, health, medical news freaking you out? Do the Double X Double-Take first!  So let's apply this to some of the article about this topic, shall we?

1) Skip the Headline.  This one is hard (for me anyway), but remember that these titles often employ the Appeal to Emotion fallacy to get your attention.  (I think a lot of your friends that post these articles on social media use this appeal as well!).

2) What is the Basis of the Article? Some news articles will make it easy to find the original article (like this one), with other articles you will need Google as your friend to input as much detail as you can find--I used the author's name, the journal, and protein.  We also lucked out in that the entire article was available for viewing online and you didn't have to sidle up to one of your friends with access to a particular journal and/or seek out your nearest medical library to see if they had a copy of that journal.  Now if you read the article (you did, didn't you?  If not, we'll be here while you do) you can see that this article "lots of people or mice or flies, lots of data, lots of analysis, a hypothesis tested, statistics done–is considered “original research.”  So it looks like this was original research that has undergone a peer review.

3) Look at the words in the article.  Here you see words like "risk" and "association" tossed around, so, you are going to see a "correlation" here, but not necessarily a "causation."

4) Look at the original source of the information. You will also want to make sure that the journal and the article are peer reviewed and not just commentary by an "expert" as even some of the experts can have some not so scientific ideas!  In this particular case you can go to the "about" or "journal information" section to see that this is a peer reviewed journal.

5) Remember that every single person involved in what you're reading has a dog in the hunt.  Fairly self explanatory, except sometimes the speculation about what dog you have in the hunt can launch into quite the ad hominem fallacy where suddenly a person who just wants to find out about protein intake finds themselves labeled as a grant whore (and that was one of the nicer terms I've seen), etc. Michael over at Skeptical Raptor sums up his frustration with this statement quite nicely: "The problem with actually trying to dismiss these accusations is that it’s nearly impossible to dismiss the accusations with evidence, because as we know, proving the negative is almost impossible."

6) Ask a scientist.  What do I think about this?  I'm so glad you asked!  Other than the "correlation does not equal causation statement I found some other points to ponder:
--The human data was observational and appeared to rely on people reporting intake, meaning that people could have over or under reported their protein intake.  Do you remember exactly how much you ate yesterday?  Last week?  Last year?
--The study didn't appear to take into account how much or what type of carbohydrate the people ate.  If they ate a bunch of white flour with their protein, and therefore consumed extra calories and/or increased your risk of blood glucose related issues, that could increase your mortality.  At the same time, the people eating less animal protein could have been eating less sugar and engaging in the other healthy behaviors as well.
--I didn't see mention of taking the amount and/or type of fat into account either.
--What about fruit and vegetable intake?
--What about exercise?
--What about the different between feedlot beef and grass-fed, or farm raised fish vs. wild caught, etc?
--Human beings aren't the same as rats, although you can use the info from the animal studies as the basis for future human studies.
--If you actually look at some of diets pointed out as being problematic, like the Atkins', they don't usually advocate "high protein" as even too much protein can cause problems with blood glucose levels, etc.   Loads of cheese isn't part of the Paleo plan either.
--A lot of the news article neglected to mention that a higher protein intake can be beneficial for older adults.
--Going overboard on anything will probably hurt you.

So what should we do with this information?
1) Don't smoke tobacco.
2) Figure out what your protein needs really are.  (0.8-1 gm protein per kg body weight on average, and for older adults it might be more like 1-1.2 gm protein per kg body weight).  The very overweight/obese might need to use a "lean body mass calculator" to get an estimate on what "weight" to use to calculate protein needs (some need more protein at the beginning of their weight loss plan to maintain lean body mass and then it will reduce as you lose weight)
3) Find out how much protein in is the food that you are eating.  If you are reading this, you probably have regular or semi-regular access to the Internet and can easily access sites like calorieking.com.  Keep a record of how much you're eating for at least 3 days.
4) Limit or avoid added sugars and processed carbohydrates, choose fresh fruit and tubers for your starches as often as you can.  If you tolerate grains, choose unprocessed ones. (Hint, most bread products are "made with whole grain" and not actually whole grain.)
5) Consume vegetables at every meal.
6) Avoid deep fried foods and trans fats.
7) If you tolerate vegetable protein sources, find ways to incorporate them (legumes aren't part of my low FODMAPS plan), but that doesn't mean other people can't include them.
8) Find ways to be as active as possible.

Take home message--Always question the news articles you read, particularly if they appeal to emotion.  Finding out how much protein you are eating, from any source, and not overdoing can help you meet your health goals.

Tuesday, March 4, 2014

Opinion: New Food Label

Last night I had the privilege to chat with dentists Jason and Grant of the Prism Podcast about diabetes, nutrition and pseudoscience, and my favorite gluten free beer (It's Omission by the way).  I was asked about my thoughts on the new nutrition label, and I thought I would expand on my thoughts in writing (which has always been my preferred medium of expression over the spoken word anyway).

Currently there are two different label formats that are proposed, as shown in this graphic from the Washington Post:

What I like about the proposed changes to the "new" label:

1) I like to have easy access to basic information about food, and I like for my patients/clients to have the same access.  Not everybody is equipped with smart phones to be able to look up information in the grocery store, and not everyone has Internet access at home to make up their grocery list either.

2) I like the bigger print for the serving sizes and calories, particularly since I work with a population that tends to have diminishing eye sight.

3) I like the addition of the mineral "potassium" to the food label.  One of the unfortunate consequences of being a diabetes educator is that you wind up working with people who have already developed kidney failure (usually from uncontrolled diabetes, uncontrolled blood pressure, or both)and they have to be cognizant of how much potassium they take in since the kidneys can no longer filter any excess potassium.

4) There has been an effort to make the serving sizes more in line with what
people might actually eat.

What I don't like about the proposed changes/wish they would have done differently:

1)  I wish they would leave the percentages off, as I have never found them useful in teaching people how to read a food label.  Who wants to calculate a percentage while they are in the grocery store anyway?  Many people already don't have a framework for how many calories, carbohydrate grams, etc they should have--and those that do have a framework are going to look at the calories/grams, etc and not look at the percentage.

2) I wish they would do away with the serving sizes and give the information for the entire container.  It would remove one more way that food companies can manipulate the serving size to cause a product to look healthier than what it really is, and I think more people would rather adjust for their own serving size.

3) I hope they don't go with proposal 2, as it's a more crowded format, they are still emphasizing saturated fat as a problem (when it's not really) while ignoring the added sugars, and once again I don't think people respond well to being "told" what to do either.

For those of you who are wanting to establish a good framework for how many calories you need, etc, I recommend the use of the Body Weight Simulator as it uses the most up to date info on how much to cut back over time and what to do to maintain your weight.  For those of you with diabetes/re-diabetes/insulin resistant conditions who are trying to figure out your carbohydrate intake, your ball park intake will be no more than 100 grams of carbohydrate per day if you are trying to lose weight and no more than 150 grams per day if you are trying to maintain (and that's just ball park, if you have diabetes you will only figure out your optimum intake by testing your blood glucose before and after meals when trying new foods.  Try not to aim for more than a 30 mg/dL increase 2 hours after eating).

For other info on label reading and portion control from this blog:
Label reading: Carbohydrate Edition
Portion Distortion
Grocery Shopping with Radio Lab



Monday, March 3, 2014

On My Reading List: The Diet Fix

I have been asked before to do a blog post about "diet books that don't contain a lot of woo."  I've avoided doing that post because even though I can think of books that have good information, I have trouble finding ones that also do not contain a lot of ad hominem fallacies or that promote enough flexibility to keep the plan sustainable.  Today, as I was catching up on blog postings from ScienceBasedMedicine.org I found one that looks promising: The Diet Fix, by Yoni Freedhoff, MD.

I say "looks promising" because it won't be published until tomorrow (I have pre-ordered), and because I like the highlights that Scott Gavura gave over at this this blog post.  I am also happy because it looks like we might finally have a book that does not ascribe demonic powers to either saturated fat (yay bacon and coconut oil!) or all carbohydrates for all people.  I also like his (seeming) focus on sustainability and self awareness (i.e. a diet plan only works as long as you have a plan for that pasta taking a leap into your shopping cart).  I'm also looking forward to reading a book that doesn't contain references to toxins/detoxing/cleansing.

I'm still waiting, however, to check out his references and look at the kind of language he uses.  I'm already wishing he hadn't used the term "Post Traumatic Dieting Disorder" as many of my patients with Post Traumatic Stress Disorder (PTSD) have eating problems that are tied up with their PTSD and I would really hate to draw a false equivalency.

Will report back with my findings/thoughts.  Meanwhile, if your reading list isn't long enough, check out this Goodreads list of recommended books:  Science Based Medicine Recommends.





Wednesday, February 19, 2014

The Brain Diet?

Immediately after I typed the title for this blog I realized that those who know me, and my twisted sense of humor, would assume that I was making a zombie joke.  While I do entertain a fondness for The Walking Dead (both the graphic novels and the TV show) I actually happen to be referring to an article that was linked from a blog post giving otherwise good advice on helping your loved ones who have depression; the related tip involved making healthy food for people whose desire to get out of bed, let alone go to a grocery store and cook, is little to none.  While the tips were actually very good (speaking from my experience), this article linked to this post which had me asking why I click on links in the first place.  Is there any evidence to any of advice she is giving?

This article does not start off well, as she starts off talking about our depression caused by "toxins."  As I have said before, "Toxin" is usually just a modern day word for "miasma," "imbalanced humors," or even "evil spirits."  So it is a) unlikely that you can be cleansed from something that doesn't exist, and b) if you really were poisoned, it is highly unlikely that eating cilantro, eating certain herbs, eating diatomaceous earth, or juicing your vegetables will remove the poison (or clear up your depression for that matter).  Remember to, there really isn't any good evidence that organic food is always safer or healthier for you.  Now to qualify that last statement, I'm not talking about taste, environmental issues, or supporting your local farmers, or saving money by growing your own food here--that's another blog post.  the point is that this paragraph on toxins is about fear and selling a book on a pointless "cleansing" procedure.

The section foods to include for a healthy brain is another interesting mixture or information that might have some truth to it mixed in with unfounded assertions.  The assertions about obtaining adequate protein, adequate fat, adequate B vitamins, and antioxidants is good information for anybody, and basically part of a general healthy diet for anyone.  And as I've said before, this really is an "anti-depression" diet, it's a "be healthy so you don't aggravate or develop underlying health conditions that might contribute to depression" diet.  Now, the point about getting adequate fat is intriguing to me, as there have been some studies (1, 2) that indicate that a very low fat diet can also increase a risk for depression, but, as the Psychology Today article pointed out, finding the causes is complicated.  It is possible that those who ate too low in fat didn't get enough essential fats (like the omega-3s), or that they weren't getting enough fat to keep them satiated at meals and the subsequent hunger influenced depression, or that they replaced the fat with refined carbohydrates which led to blood glucose regulation issues which influenced depression, or maybe some combination thereof.  I also find the link between gut bacteria and depression to be intriguing, but there isn't really a clear link there either (Link).

When it comes to testing urine for neurotransmitters, I recommend reading this excellent post from SciencebasedMedicine.org: Bogus Diagnostic Tests.  Neurotransmitters are found in other tissues in the body (peripheral), and so any neurotransmitters that appear in the urine do not reflect the levels in the brain.   As far as the supplements are concerned, remember that you don't need to supplement unless you are deficient, and that "natural" does not mean better or free of side effects.  Notice that one of the supplements recommended, 5-HTP, has been associated with dizziness, nausea, and diarrhea (Link).

Several of the lifestyle changes like getting adequate sleep, meditation, limiting alcohol, and exercise have evidence to back them up, the others, not so much.  Also remember too that when I talk about eating in such a way as to not aggravate other health conditions, I am not talking about dubious diagnoses like "Dubious Yeast Allergies."

Take home message--Eating a healthy diet, particularly with the help of loved ones when you don't feel like cooking, can help alleviate symptoms of depression.  Unfortunately there are no certain "magic" foods or supplements that will relieve it.





Tuesday, February 11, 2014

Rehydration Solutions?

The norovirus has been in the news lately thanks to outbreaks at local schools and on a few cruise ships. As people recover from this illness the focus is often on rehdyration (replacing fluid loss from diarrhea and/or vomiting) as well as electrolyte replacement (replacing sodium and potassium lost from diarrhea and/or vomiting). You also want to make sure that the beverages that you use don't aggravate any nausea or diarrhea that you might currently have and make sure that the solution can be absorbed by the digestive system efficiently. Of course many people who are feeling terrible (or feeling stressed from caring for an ill person) will reach for what is readily available, which is often a sports drink such as Gatorade or Powerade or even just a regular sugary drink like a soft drink or kool-aid. But are these really the best things to offer for oral rehydration therapy after severe illness?
 
The evidence points to the answer being no for a variety of different reasons. First of all, the sports drinks like Gatorade may have enough sodium/potassium to replace sweat losses but not to replace losses from protracted/frequent vomiting and diarrhea. Second of all, the amount of sugar in sports drinks, and some sodas/sugar beverages, causes them to have a 
high-osmolarity and can actually cause diarrhea and therefore more fluid/electrolyte losses. Third, sugary drinks like sodas also don't have the sodium and potassium needed to replace electrolyte losses. Fourth, some of the carbonated beverages might cause more stomach distension and promote that nauseated feeling.
 
A better option would be to choose a solution formulated to have the right amount of sodium, potassium and glucose (sugar) such as Pedialyte. For those of you who want to have additional control over the taste and flavoring of the solution, you can also make your own oral rehydration solution using this recipe used by the World Health Organization:
  • 2 level Tablespoons (TBSP) of sugar
  • ½ level teaspoon (tsp) of table salt (sodium chloride)
  • ½ level teaspoon (tsp) of salt substitute such as No Salt (potassium chloride)
  • ½ level teaspoon (tsp) of baking soda, dissolved into
  • 4¼ cups (1 liter) of clean water
  • Add your favorite sugar free beverage mix to improve the taste.

  • All that said, an oral rehydration solution is only useful if to the sick person if he/she is willing to drink it.  (One of my co-workers told me a story about how his cranky toddler threw a Pedialyte popsicle at him after tasting it).  So you might be better off mixing your own where you can control the taste.
     
    Also:
    • You might be able to to get away with using Gatorade, etc if your diarrhea/vomiting was very mild.
    • Infants, frail elderly, and those who are immunocompromised are at a higher risk for dehydration and may need medical care.
    • If you show signs of severe dehydration you need to seek medical care.
    Take home message--A commercial rehydration solution such as Pedialyte or a homemade solution is more appropriate for rehydration after suffering losses from severe diarrhea and/or vomiting.




    Thursday, February 6, 2014

    Coconut oil for Everything?

    Those familiar with this blog will be familiar with my love of infographics, where I get to dissect them, that is.  So I was happy to see this appear in my feed to provide some blog fodder:

    Coconut oil is a boon for those of us who don't eat dairy (for allergy or avoidance of animal products)but still need a cooking fat that will take high heat (think roasting vegetables), give a good mouth feel comparable to butter (think pie crust), can provide a creamy texture to soups (like a butternut squash bisque) and curries.  But does it actually provide the above benefits?

    1) Thyroid stimulating.  There are no reliable sources or studies that indicate that coconut oil can help get people off their thyroid medication, not to mention that this particular paragraph says anything about the thyroid at all.  As far as increasing your metabolism, the consistent use of coconut might help you burn a whopping 25-50 more calories a day.  Every little bit helps, but keep in mind that 1/4 to 1/2 a slice of bread will give you 25-50 calories.  So you still don't have much wiggle room there (Link)

    2) Lowers cholesterol.  The lauric acid can raise both HDL and LDL, which might improve the overall lipid profile, particularly if you are a lab rat.  The human data is a little more sketchy. (Link). 

    3) Helps keep diabetes in check.  There isn't any evidence that coconut oil stimulates the pancreas to produce more insulin, nor would this necessarily be beneficial if it did (because in the early stages of Type 2 diabetes the individual may be over producing insulin but the body can't use it efficiently).    There is a possibility that coconut oil might improve one's sensitivity to insulin, which could ultimately help an individual have better blood glucose control or prevent the progression from pre-diabetes to diabetes, but we don't have enough good human studies to recommend it as a treatment.

    4) Gastrointestinal malabsorption. Once again, there is no evidence that coconut oil applied to the skin can help people with fat absorption issues prevent fatty acid deficiency.  The only human studies I could find used sunflower oil, and even those were small and requiring more research.  Since coconut oil contains medium chain triglycerides, they do not require bile salts for digestion and passively absorb through the GI tract into the liver.  This is a boon for those with fat malabsorption problems, but you still have to take it orally.

    5)  Helps with weight loss. The ways this is worded it makes it sound like any other fat would go immediately to the fat stores in your body, which sounds an awful lot like that tired old Weight Watchers' saying "A moment on the lips, a lifetime on the hips!"   Of course, the body's ways of digesting, metabolizing, and storing is more complicated than that.  I think what they might be getting at here is the problem/question that many people trying lose weight have to face, "How do I cut back on "x" without facing hunger that so intense that I can't think straight?"  (There are many variations on that same question).  Fat is satiating so those who try to cut out ALL fat will probably wind up with excessive hunger and have trouble keeping with their plan (or having a good quality of life).  People who consume fat with abandon (and don't cut out the extra calories somewhere else) will have trouble losing weight as well.  So an easily absorbed satiating fat, taken in the context of you cutting out calories somewhere else could be a useful tool in your weight loss regimen.

    6) Kills Candida.  I think in this case they are actually referring to a condition that Quackwatch calls the "Dubious Yeast Allergy" category, you can read Dr. Stephen Barrett's article about this here.  You can't actually kill off a disorder that doesn't exist.

    7) Supports the Immune System. The lauric acid has actually been studied as an anti-microbial agent in the treatment of acne, but no good studies exist as far as eating coconut oil to stave off the flu, etc.  And remember, you may not want to "boost your immunity."

    8) Reduces Heart Disease.  There is a correlative link, but not a causative one in this case.  Although it does cast doubt on the theory that all saturated fats raise your risk for heart disease.

    9) Nourishing for the Brain.  There was one doctor who performed one case study that said her husband's symptoms of Alzheimer's Disease improved through the use of coconut oil, but there have been no peer reviewed studies to support this. (Link)

    10) Good for the Skin.  This one actually shows some promise, at least in animal studies. (Link).  Applying non-medical grade oil to any open wound would not be recommended, however.

    Take home message--Including coconut oil as part of a portion controlled plan for weight loss and a carbohydrate controlled plan for diabetes can be useful, but don't expect a magical drop in weight.