Thursday, August 30, 2012

Opinion: Why I hate Workplace weight loss programs.

At least once per year where I work they offer up a "Biggest Loser" type program where people compete against each other to see who loses the most weight.  There is a prize given at the end and the person gets to lord it over their co-workers until….the next context I suppose.  These type of things make me want to go and hide for a variety of different reasons:
1) Your total weight is not always a good marker of your health.  As I talked about in this post, someone might have a high BMI but have good lean body mass and body fat percentage.  Someone else might be at what appears to be a healthy weight and still have issues with inflammation, out of control lipids, or even poor blood pressure control.
2) There are "weight classes" when it comes to boxing and mixed martial arts, but there aren't any "weight classes" for any of the workplace weight loss competitions that I've seen.   If your weight loss competition is over a few months, that person who has 50-100# to lose (and is losing!) is going to be "ahead" in the weight loss category over someone who has to lose 5-10# (especially if the very obese person goes on a very low carbohydrate diet they are going to have a huge water weight loss).  If the weight loss competition is short term, once again that person who has more to lose is going to come out ahead.
3) Work place weight loss competitions often pit men and women against each other.   Many people have observed that men do lose weight faster than women do, and there are genetic and social differences that account for this.  Men typically have a genetically higher resting metabolism—the energy required for basic functions of living like chewing food, digestion, and blood circulation.   Since men also tend to have a higher percentage of muscle, this also contributes to a higher metabolism.   Social reasons that can impede weight loss is that in many households women are still the primary meal preparers (not all households)—the planning of menus, trying new recipes, grocery shopping, and preparing of meals provides a lot more opportunities to nibble/taste and therefore consume more calories.  [Link].   I see no logical reason to lump people together in a contest when one group clearly has a metabolic advantage.
4) I feel like the competition atmosphere provides more opportunities for people to sabotage each other instead of helping each other out.  Some people might enjoy the challenge of having a co-worker sit a bag of Oreos on their desk, other people find that sabotage just makes them want to drop out.  One of things important to changing your eating habits and maintaining weight loss is the support of friends and family.  I haven't seen too much support going on in our employee weight loss program.  Some of the pranks are good natured between friends, others are downright mean and selfish.  Wouldn't it be more beneficial to have people compete against themselves only and form support groups, healthy potlucks, etc?
5) What happens after the contest is over?  So if you went on a cabbage soup or other "faddish" diet and lost a bunch of weight for a few weeks, are you really any healthier?  Especially if you lost muscle mass by going on the crash diet?  Probably not.  What if you eat a "healthy" plan that promotes fat loss over muscle mass, but right after the competition's over you go back to your old habits and gain all the weight back?  Losing weight is often easy, it's the maintenance that most people have problems with.    If you lose a bunch of weight and then gain it all back, you are probably not improving your health.
6) There typically aren't any incentives to keep the weight off.  Any follow up competition?  Can you get dollars taken off your insurance premiums?  Any special workplace recognition if you stay at your goal weight or lose more?    Some places do offer end of the year/point accumulation incentives, but once again that's not always the case.
If you are going to help your employees get healthier and maintain their weight loss you can do it by creating a more supportive environment, not by putting people at each other's throats.

Tuesday, August 28, 2012

Today's buzzword: Inflammation

One of the buzzwords thrown around in nutrition circles lately is the term "inflammation."  It seems like every food we eat or activity we do can be labeled pro or anti-inflammatory.  But what does the science say?

First of all, not all inflammation is created equal.  First of all we have acute inflammation, which is usually caused by an injury such as getting punched in the face, cutting your leg while cleaning up your adopt-a-highway section (ask me how I know!), or getting exposed to a virus. What follows is a fascinating (to me) process that combines both a repair cycle and a "do not use" order.  First, something called pattern recognition receptors (PRR) located at sight of the injury/virus exposure call up various inflammatory mediators which then start a process called vasodilation (widening of the blood vessels). More blood flows to the injury site, which causes it to feel warm and turn red. The blood vessels become more permeable (think of little doors opening up in your blood vessels), which  allows plasma and leukocytes (white blood cells--five different types that target different pathogens!) to flow through the vessel walls and into the injured tissue to do their work. This increase in plasma causes the swelling you see.  While that's going on, your body releases an inflammatory mediator called bradykinin which causes you to feel more pain at the sight of injury. So, not only is the swelling, redness, heat, and pain a sign that something is going on, but you are less likely to use the affected area (or do anything if you've got a really bad cold) and allow the "repair people" and "cleanup crew" to do their jobs.  (Would you interrupt a skilled technician doing delicate electrical work in your home?  Or a janitor cleaning up a, um, body fluid spill?  I don't think so!)

Now, if said process continues longer than the acute period, it is said to be chronic inflammation, and sometimes the products of inflammation can cause disease itself.  For example, when a person who has dermatitis herpitiformis ingests something with gluten there is going to be a nasty rash that results.   If someone with asthma is exposed to tobacco smoke or paint fumes they better have an inhaler handy.  And there is also evidence that inflammation plays a role in heart disease (Link), and cancer (Link). 

For those of you who are trying to avoid pain and inflammation from an injury or virus exposure, you are probably going to try to avoid the causes.  You might wear long pants to keep from getting cut on your adopt-a-highway cleanup (but it was hot outside, ok!) and you will hopefully was your hands frequently during cold and flu season.  If you are having a life-threatening reaction, you might even have to (gasp!) take some kind of (gasp again!) medicine to help you well, live.  When it comes to avoiding chronic inflammation, however, here is where we have to dig deeper.  And since this is a nutrition blog we will look at diet and inflammation.

So what causes the ACUTE inflammatory response?  Well, everything apparently.  Food, in general is going to have something the body perceived as a foreign object in it, and we have an acute response until the body takes care of assimilating the nutrients.  Plenty of studies have measured post-meal reponses. (1, 2, ), and it appears after 250,000 years we have adapted pretty well to that.   And of course it's the long term inflammation associated with the C-words that we are probably more worried about.  It appears that there are some other studies pointing to either a high processed carbohydrate diet as problematic for inflammation, other studies point towards specific types of carbohydrate foods like those who contain gluten as promoting inflammation markers, and some studies point toward saturated fats causing inflammation, but a lot of these studies involve a very small group of people (larger double blind studies are more expensive) or rely on the notoriously unreliable food questionnaires, so they are there for us to say "huh, that's interesting" but hardly pivotal. (1, 2, 3)  So, in other words, as badly as some of us want to point the finger at one particular food or group of food, it looks like, in the words of Dr. Ben Goldacre at Bad Science, it's more complicated than that.

And those complications involved some other physiological issues like insulin resistance, obesity, fatty-liver disease, how much and what type of exercise we do, etc. (1, 2, 3)  But wait a minute here, can't some of these other problems be corrected by diet as well?  Well, yes, it looks like we have circled around again.  If you are a person who is insulin resistant, in other words you have the marker's for metabolic syndrome, or have been diagnosed with pre-diabetes or Type 2 diabetes, or have been told your triglycerides are high, you can improve your insulin sensitivity and see improvement in your clinical marker's by restricting your carbohydrate intake.  (And please, go to your physician and get your lab work done, no internet diagnosing!) (Link).  And if you restrict your carbohydrates (in other words, you stop drinking a ton of soda and eating platefuls of pasta, you know who you are!) then your calorie intake has a pretty good chance of decreasing so you can lose weight (and people find when they are producing less insulin, they may not be as hungry either).  And by the way, if you have fatty deposits in the liver, restricting the carbohydrates might help you there to.  So does eliminating or restricting one food group cure your inflammation? Apparently not.  Could it lead to some improvements in other health markers and therefore lower your risk of heart disease and cancer?  Possibly, but for now the improvement in other health conditions might have to be our main staying point. (Link)

But what about the omega-3 fats?  Aren't they the cure all for inflammation?  A lot of my patients think so, and they feel like as long as they take those fish oil capsules faithfully they don't have to make any other changes in their diet.   Remember, there are no magic cures!  And it also appears that if people are taking their fish oil capsules faithfully but still consuming a lot of omega-6 fats, it's not going to produce a favorable response.  Both of those fats are essential, meaning our body doesn't make them, but apparently if we tip the balance toward omega-3 and away from as much omega-6 our inflammation markers decrease.  One of the better postings I have found on this topic is over at Caveman Doctor.  His blog persona is a bit goofy (hello pot, meet kettle) but he does some pretty solid research.

Speaking of, he also has an interesting post on exercise and inflammation.  If you are distance/endurance athlete and are having joint problems, you might want to take a look at your routine and see if it's time for a change.  Now, using the small data set of Friends of SkepticRD Who Enjoy Cheating Death by Triathlon and Other Scary Things, I know that there are people who love being endurance athletes for a host of reasons.  As I stated in a previous post you can't expect to have a poor diet and compete well anyway; but we'll need to do some more studies to show if the diet also helps reduce inflammatory markers in that particular subset of the population.

Now what about other issues attributed to inflammation such as lupus, rheumatoid arthritis, etc?  Can diet "cure"  those problems as well?  There are some people who think so.  First of all, as stated above, not all inflammation is the same.  For example, if I have an infected cut on my leg, changing what I eat will not directly heal that infection.  Second, you can always point at a particular food and group of foods and say "this will stop it," but you might have other underlying health problems that may be helped by a change in diet.  For example, if you have uncontrolled diabetes and have an infected cut on your leg, changing your diet can lower your blood glucose levels and promote wound healing that way, but there was no one food that will do so.  Third, a lot of the diets that people follow for rheumatoid arthritis, etc have a large placebo effect, and as they say in this WebMD article "some people find relief and some people don't."  I usually tell people to think about the ramifications of what they are giving up in a "first do no harm" kind of way.  For example, if you think gluten is aggravating your rheumatoid arthritis, giving it up for 2-4 weeks may result in you being very, very cranky because you won't be drinking beer and eating pizza, etc for that time, but as long as you are eating protein/good fats/vegetables you won't wind up with a nutrition deficiency.  If you give up gluten and animal protein, however, then you might find yourself cranky and having to work hard to get quality protein.  Some people are willing to take that chance for pain relief, others that follow the evidence will not.

Take home message--consuming more omega-3 fats and less omega-6 shows the most promise for reducing inflammatory markers.  If you are obese and/or have a condition that involves insulin resistance you will likely benefit from restricting your carbohydrate intake to improve health marker's associated with those conditions.  If you think that other foods are aggravating a particular condition that you have; think about the ramifications about eliminating that food before you try it.

Saturday, August 25, 2012

A Weighty Question

Another common question that I get asked on a fairly regular basis "What should I weigh?"  Of course the mere phrasing of the question implies that if you fall short of some particular "ideal" then you may be flawed in character as well as body.  What I would prefer is that we would someday ask, "Am I at a healthy weight for me?" or "Is my percent body fat in a healthy range?" or even "Does my body fat put me more at risk for certain health conditions?"  The last few phrases are more suggestive of each individual looking at his or her state of health based on more than one factor versus us all trying to measure up to a particular standard.  But since old habits, and old questions, die hard, here are a few questions that you might want to ask yourself first.

First of all, ask yourself "What was the last weight I felt good at?"  Don't worry about any charts, etc at this point.  It might be five pounds less, it might be fifty, but this is one of the first steps in looking at you as an individual.  Next, ask yourself if you think that is a realistic weight.  Have you had a few birthday's since then?  Do you have to take medications (for now anyway) that might keep you from losing weight?  Third, ask yourself honestly if you are willing to do the work, yes I said work, involved in getting to a particular weight.   And remember it's not just work to get to that weight, it's work to keep it off as well.

Now as far as something that has more hard science to it, there are some other ways to assess your health risk.  First of all, when looking at yourself, you shouldn't use the Body Mass Index (BMI).  Yes, you read that correctly.  Why not?  Well, this three year old article written in Slate gives a great history of BMI and contains a critical phrase: "The cheap and easy BMI test allowed them to plan and execute ambitious new studies involving hundreds of thousands of participants and to go back through troves of historical height and weight data and estimate levels of obesity in previous decades."  In other words, the BMI is only useful when doing an overview of populations for research purposes or to implement as a screening tool, but not to make clinical judgements on individual health.  For example, let's say a University is recruiting people for a study, and one of the criterion is that participants be obese.  This happens to be a study where participants will receive some monetary compensation for their participation, so the researchers get flooded with applicants.  Because of time constraints, and funding constraints, the researchers need to do some "weeding." (aka screening)  One of the easiest ways to "weed" out non-overweight or obese individuals is to look at their BMI.  So, in this case, the BMI had a legitimate use as a reasearch/screening tool as no judgements were made.

So, if your physician or another health care person makes a comment about your BMI and tells you that it's high/low or good/bad, etc, you can tell him/her that that was an inappropriate use of that tool.  What you need to do is whip out your tape measure and have them do a Waist-to-Hip Ratio (WHR).  If you are equipped with a smartphone and/or the health care person has internet, you can even whip out the Wikipedia article on where to do the measurement, and also charts on risk assessment. This is a better health risk assessment based on where you might be carrying your excess adipose (fatty) tissue, and relatively easy to perform even if it is more "hands on." (Link).  Occasionally you might even find a physician and/or Registered Dietitian that has been specially trained in measuring body fat percentage using skinfold calipers, but I've seen that more commonly used by personal trainers at gyms.  If you are lucky enough to be associated with a university you might even witness or get to participate in hydrostatic weighing.

Once you've done your WHR or body fat assessment, if you are in the high risk and/or high body fat percentage, you probably still have a weight loss goal in your mind.  Keep in mind there is evidence that losing just 7-10% of your excess weight shows benefits in lowering obesity-associated health risks (Link).  No reason why you shouldn't aim for lower, if it improves your health status, but sometimes a lower short term goal might seem more attainable and realistic.

Take home message--use methods meant to be tailored to individuals when looking at your weight loss goals.

Friday, August 24, 2012

Weight loss programs I wish would go away #2: The HCG diet.

SkepticRD had the good fortune to have a good science-based education and do a dietetic internship where I was taught to look at new research and new treatments with a critical eye.  Once I graduated I had the idea that anyone who survived the rigors of obtaining their health care degree/license/registration would have that same critical eye and be aware of how their own body worked.  I don't think that delusion lasted for more than a month once I overhead what other other health care people were telling their patients and even what I saw them try to do for themselves when it came to what I call "Food and Diet Woo."  Here in Skepticville one of "things people who should know better but don't" are doing is the HCG diet.

First, a little history, as this plan is not new but a recirculation of something that's been around for about 50-60 years.   Apparently a German endocrinologist by the name of ATW Simeons was the first use to the hormone human chorionic gonadotropin (HCG) to help people lose weight after publishing his book in 1954.  I noticed that it was difficult to get information on this person from a reliable internet source (which should be a red flag there) but apparently he either noticed the weight loss side effects when either a) treating adolescent males with low testosterone, or b) he noticed that women living in third world countries were still giving birth to "healthy" babies even though they were on "starvation diets."  He then formulated a regimen combining weekly injections of HCG with a 500 calorie a day diet and a new weight loss plan was formed.  This plan enjoyed a resurgence around 2007 when Kevin Trudeau published his book "The weight loss cure they don't want you to know about.

As I mentioned before, the fact that it was hard to find reliable information on the author of this plan, although his 50 page booklet on obesity is free for download for your reading pleasure.  Once again, the fact that it was hard to find reliable websites that contained information on him was one red flag, another red flag was the story about the starving women giving birth to supposedly healthy babies.  The impact of poor nutrition during pregnancy has been fairly well established (Link) so I would be curious to see how healthy these children were.  The third red flag was that the supplement was done in conjunction with a very low calorie diet, which would help people lose weight anyway even if it wasn't very pleasant to follow.  Fourth, the title of Kevin Trudeau's book, which speaks of conspiracy theories and persecution is one of the major red flags in the Baloney Detection Kit.

Then of course there is the question, "Is there any evidence that this works?"  Stephen Barrett, MD over at and has already compiled a pretty extensive list of studies that say "no." (Link)  One of things that I worry about is the long term consequences.  First of all, it is very hard to meet your protein and fat needs to maintain your lean body mass and cell wall integrity on that low of a calorie diet.  Possible, but difficult.  Second of all, what about maintaining weight loss in the long term?  Losing weight can be quite easy actually; it's keeping it off that's the problem.  In order to keep that weight off you need to find a program you can live with most of the time, and preferably a way of eating where you actually enjoy what you eat!  Third, we don't know too much about the long term consequences of playing with this type of hormonal treatment.  Of course, HCG is a "natural" hormone that helps women who have infertility, but there are other "natural" hormones that our bodies produce that can have devastating consequences when out of balance, like insulin for instance.

There is also (always!) the cost of the program.  Apparently some insurance programs will cover injections but you are still paying a co-pay.  And if you really want to waste your money you can buy the "herbal" or "homeopathic" version. There are many articles on why homeopathy is junk science, but here's favorite by SkepticHero Dr. Harriet Hall.  And even if there is actually enough HCG in something, this type of hormone is what we call a polypeptide hormone which will be broken down in your stomach and rendered useless.  Just like insulin has to be given via injection for it to work, this type of hormonal treatment requires injections as well.

Take home message--not enough evidence to support the HCG diet for long term weight loss.  And unless you want to dissolve away your money, don't use the herbal formulation.

Tuesday, August 21, 2012

It's Not Easy Being Green (Vegetables)

So in yesterday's post I reminded you all that vitamin supplements are not vegetables. And maybe some of you are thinking you should eat more of them to provide you with fiber and help you fill up on something that doesn't have a lot of calories.  You are interested in not spending extra money on something that likely won't do you any good and might even harm you.  But you've got all of these excuses for not eating vegetables.  Here are some of the common ones I hear and something you can  do about them.

1) I don't like vegetables.  I know what this is like.  The other day Boyfriend of SkepticRD was treated to a rant about how an entire dish of red curry was ruined for me because that particular restaurant put peas in it.  But chances are there is at least one vegetable that you like, so concentrate on eating more of it first.  For example, if the only vegetable you like is tomatoes, look up recipes for different kinds of salsa, make it into soups, etc.  In the course of recipe experimenting you will probably find some new flavorings that will help you venture out into other vegetables.  You can also try hiding them in thick and hearty soups or pureeing them into pasta sauces.  Try some vegetables raw and some cooked as some people do better with one texture over another.  And don't be afraid to flavor them with healthy fats like olive oil, coconut oil, drippings from the roast you made, or even nitrate-free bacon! 

2) Vegetables are expensive.  I do work with people who have very limited incomes, and food security is a real problem.  Depending on your situation you might qualify to get foods at a local pantry, and some pantries are actually able to supplement with produce from community gardens.  If you have transportation to a local farmer's market, try negotiating with the local farmers at the end of the day when they are trying to sell some of the produce that's not as "pretty."  And if it's legal in your area, you might even want to scavenge in local supermarket dumpsters.  For people who have adequate income but are still not trying to be wasteful, you can save money by buying frozen vegetables in bulk or even buying fresh ones on sale/in season and freezing for later.  Once again check out Farmer's markets to buy in season and negotiate prices.  And some people might also have to take a long, hard look at where they are spending their money and cut some things out.  (For example, if you stop buying the diet soda, aka brown water that provides no nutrition value, you can probably put more money towards vegetables and other healthier things).  Start clipping coupons for frozen vegetables.  And pretty much wherever you live you can grow some vegetables whether it be in a hydroponic garden or a pot on your porch.

3) I don't live in [insert state with moderate climate] here and can't get fresh vegetables all the time.  Keep in mind that for a large chunk of human history people did not have the means or funds to ship vegetables from thousands of miles away or large supermarkets to buy them in.  People relied on canning their vegetables, tucking tubers away in dark basements, and as refrigeration became more accessible then people began to freeze vegetables also.  It is still possible to do a form of this today by relying on frozen vegetables that can be steamed, worked into soups/stews/casseroles, baked into quiches and frittatas for breakfast (or any time of day!), stir fried with protein, or even blended into smoothies.  You can buy a cube or chest freezer to buy vegetables in season and freeze them for winter or buy bulk frozen vegetables.  Vacuum sealers also work wonders for saving vegetables in the fridge or freezer. You can learn to do your own canning or look for canned no added salt vegetables.  Or, once again you can experiment with growing your own vegetables hydroponically or in a mini greenhouse in your home.  My eighty something year old grandparents have a one bedroom apartment in their retirement community where they store sweet potatoes under the bed, put vegetables in their chest freezer, and do a small amount of canning.

4) I don't live in an area that has a lot of fresh vegetables available.  This is another tough one, as a great many of my patients are limited when it comes to their mobility and use of public transportation.  Once again, if you are old enough or infirm enough you might qualify for a supplemental program like Meals on Wheels—they usually have to provide at least one vegetable as part of their program.  Or see if you qualify for a food delivery box from a local food pantry or church—your vegetables will be canned so rinse them well before cooking if you have trouble with retaining fluid from too much sodium.  If you are more mobile and can take public transportation, purchase some large tote bags to take to farmer’s markets; once again you can typically negotiate with the farmers on buying smaller portions.  You can also buy mini coolers and insulated tote bags to help you take more frozen vegetables from the closest grocery store back with you.

5) Can't I just buy fruit and vegetable juices?  See my previous post about the pros and cons of "juicing."  What I will repeat here is that usually it's too easy to get a carb/calorie overload with juices, you don't get the fiber you need, and liquid calories do not provide the satiety value that solid food does which can promote overeating later.

6) I’m too busy.  You can find pre-cut vegetables in just about any grocery store and even in gas stations these days.  You can place frozen vegetables or fresh pre-cut vegetables in the crock pot with protein or in the oven, or even throw them on the grill.  If you choose to patronize fast food places, you can get garden salads for relatively low cost.  Now, if you want to save even more money, wash/chop/freeze/vacuum seal your vegetables on the day you do grocery shopping and then you don’t have to worry about it for a while.

Take home message—Yes, it does take work to get your vegetables in, but it will get easier once you actually get into the habit.  Keep in mind too that if you have financial and transportation issues there may be help out there for you if you are willing to ask.

Monday, August 20, 2012

Multi (vitamin) verses

One of the questions that I always have to ask when I meet a new patient is "Are you taking any vitamins, supplements, or herbal products that are not prescribed by your provider?"  Quite frequently the answer I get is "No, should I?"  Unless there are specific health circumstances where I can recommend a specific supplement in a specific amount, my answer is usually no.  Let's talk about why.

Kyle Hill, who is a research fellow for the James Randi Educational Foundation, has already done an excellent post entitled "The Multi-Vitamin Fallacy."  Some of the highlights of his post include 1) Two recent large scale studies indicate there is no evidence for people to take multi's and there is also evidence pointing to increased health problems and toxicity, 2) There is no regulation on supplements so you might not actually be getting what you think you are, 3) people who take vitamins often engage in other healthier behaviors such as exercising regularly and not smoking, and 4) a multi-vitamin does not compare to the hundreds of active compounds found in fruits and vegetables.  So, in other words, people who take multi's because they don't eat fruits and vegetables are still not getting the benefit of eating them and their "additional insurance" isn't working.

Now, there are plenty of people who do acknowledge that they will not get the same benefits from a multi, so their next step is to find a supplement that in their mind actually contains ground up fruit and vegetables.  One of the more popular ones out there is a product called "Juice Plus."  This product is basically fruits and vegetables that are juiced, reduced to powders, fortified with a bit of extra fiber and enzymes, and then sold to the public through multi-level marketing.  The major selling point basically boils down to that we as busy people do not eat enough fruits and vegetables and after we start taking this product pretty much any health ailment that we suffer will somehow start to improve within a few days of taking this product.  Now if you are a skeptic that fact that this product is not ailment specific (i.e. is an all purpose cure) should start the warning bells in your head ringing.  So lets take a more detailed look at Juice Plus.

First of the recommendation that people eat 5-9 servings of fruit and vegetables per day was not to prevent vitamin deficiencies as you can get an adequate intake of various vitamins and minerals on far fewer servings. (Keep in mind that we get vitamins and minerals even when we eat protein sources as well, and as Kyle said in his article, our bodies are pretty efficient at using what we do get!).  The recommendation was to help people eat enough fiber and also to help people "fill up" on lower calorie nutrient dense foods and not fill up on higher calorie foods; in other words, more fruits and vegetables would hopefully translate into fewer fats and grains.  And guess what, just about any diet plan you look at from low carb to the Myplate has a fairly sizeable chunk of the plate as vegetables.  Barbara Rolls, a researcher at Penn State University, has actually published her research about using high nutrient/low calories foods to create a "bigger plate" that helps you eat fewer calories/carbs and still feel full.  Now, if you don't try to fill up on vegetables and instead try to do the Juice Plus, you probably won't get the same satiety value that vegetables provide and it will be that much easier for you to overeat on starches and other caloric dense foods.  So, would this help you with your weight?  Probably not, might even make overeating a little easier too.

One of the other reasons that I have seen people take juice plus is because they have an inflammatory bowel disease such as Chron's.  Typically someone with this condition cannot tolerate raw fruits and vegetables without severe pain and diarrhea.  Chances are they also bought into the idea that people need to eat their fruits and vegetables raw in order to obtain vitamins and minerals, but as I have covered in a previous post you can still get adequate amount and some vitamins and minerals are more bioavailable through cooking.  So, a person with IBD can still take in vegetables and fruits and just do their own cooking or juicing and still get what they need without pain.  On a related note, some people who have trouble with flatulence after consuming certain vegetables might be intrigued by the "enzymes" that are added to the Juice Plus.  Unfortunately, said enzymes do not survive the acidic environment of your stomach and so they won't help you absorb the vegetables better or prevent flatulence.  Once again, eating more vegetables cooked than raw, or learning that you can't tolerate certain vegetables, will help reduce the flatulence.

Also keep in mind that the Juice Plus does have fiber added back to it, but you wind up taking in only about 4 grams of fiber.  Typically, we are going to need more fiber than that to help maintain bowel regularity, so if someone is not eating enough fruit and vegetables, they may wind up trying to supplement their fiber intake via grain products or by taking fiber supplements.  If you wind up trying to supplement your fiber intake with more grain products, you will also be upping your caloric intake and probably going over your carb limit if you have diabetes or pre-diabetes.  In other words, that one cup of steamed broccoli gives you 5 grams of fiber, 55 calories, and only 6 gm net carbs, whereas that one piece of whole grain bread gives you only 3 grams of fiber, 100 calories, and 17 gm of net carbs.  And if you choose to use the fiber supplements, well then you are going to be spending more money in the long run too.

Oh, and speaking of money, you will also be spending on average about $300-$600 a year on the Juice Plus products.  In addition to whatever else you are spending on food.  Perhaps if the lack of evidence doesn't get you, the hit to your wallet will?

Are there some circumstances where supplements are a good idea?  Yes, there are. 
1) Vitamin B12: People who choose to follow a vegan diet should supplement with this vitamin as significant amounts are only found in animal products.  Some older adults also stop producing something called "intrinsic factor" in their stomachs and can't absorb B12 from foods.  People who have had part of their stomach removed for weight loss surgery or cancer, etc will also be unable to absorb sufficient B12 and will need to supplement.  Some people who have IBD will also require supplementation.  But like anything, supplementation will only benefit you if you have one of the above conditions or are KNOWN TO BE DEFICIENT.  A simple blood test can tell you whether or not you are deficient.

2) Vitamin D.  Our bodies can actually make an adequate amount of vitamin D through sun exposure for a mere 15-20 minutes per day, but some people might still be deficient.   SkepticRD works with a mostly elderly homebound population; these are people who don't get outdoors much and even if they did, chances are their ability to make vitamin D from sun exposure has diminished with age or because of other medical problems they might have.  Once we know a person's vitamin D levels are low we have to give them a large dose every week for 8-12 weeks and once their levels are back up to normal they usually require a maintenance dose of 1000-2000 IU per day.  Once a nurse asked me about vitamin-D foods, and I looked her in the eye and asked her if she wanted to start telling our patients to drink 10 cups of milk per day or eat roughly six cans of sardines per day.  She decided to promote safe sun exposure and enforce the prescribed supplement.  Younger people who have avoided sun eposure because of fear of skin cancer or aging might also have low vitamin D levels, but once again a simple blood test from your doctor can tell you whether or not you are deficient.

3) Omega-3 fats.  Omega-3 and omega-6 fats are essential fats, meaning that our bodies do not make these and we must get them from food.  If we get more omega-6 than omega-3 it tends to increase the risk for inflammation and therefore increase risk of heart disease among other things.  Pasture raised beef, game, other foraging animals, and wild caught fish will usually have a higher omega-3 content than feedlot raised beef, caged chicken, farm-raised fish, etc.  For people who do not have ready access to grass fed beef, etc. or choose not to pay a higher price per pound they might benefit from supplementing with omega-3 fish oil.  **Interesting story, when the "new" drugs for HIV/AIDS came on the scene people's life expectancy and quality of life grew--and it also tended to send their triglycerides through the roof.  Most of our lipid specialists would send them to me to help them change their diet but they would also have them taking 9-12 500 mg fish oil capsules per day (or more) to try to combat their elevated lipids.  I still remember the guy who would be sitting on his couch and look up to find both of his cats sitting right by his head.

4) Probiotics.  See this previous post on why that may not be a good idea except in certain circumstances.

5) What if I have a cold or flu and want to "boost my immune system?"  I have also addressed this before, but Mark Crislip does a most excellent job of explaining why that is not a good idea here.

Take home message--supplements will not make up for you not eating nutrient rich low calorie fruits and vegetables.  In a follow up post I plan to talk about the many excuses people give for not eating fruits and vegetables and how to combat them.

Friday, August 17, 2012


I said I would try to inject a little bit of humor into this blog, although I will never be as laugh out loud funny as neurologist Dr. Ibee Grumpy.  Last night I had this conversation, or something like it, after two glasses of wine each:
Boyfriend of SkepticRD: Have you ever noticed that all zombies are thin?  How is that possible?  The brain is mostly fat.
SkepticRD: It's because they only consume fat and protein, they don't consume any carbohydrate.
BoSRD: So, you're saying they're all on the Atkin's Diet?
Me: Well, the cats (obligate carnivores) are on the Catkin's Diet, so that means they are on the....Zombiekins Diet?

Yes, we do talk about these things over dinner.  Of course it also led me to remember this piece from the The Onion: Zombie Nutritionist Recommends All Brain Diet.* "The Rossum Plan challenges the traditional zombie food pyramid, which consists of five to seven daily servings of human hearts, three to four servings of livers or eyeballs, and two servings of brains."

Ok, so I found this hysterical.  If you are still with me, then let's talk about research, done by the Living Dead or otherwise, how it's portrayed in the media, and how you can discern whether or not the research applies to you.  I will also touch on some of the other critiques made about diets, brain-dominant or otherwise.

First of all, remember that most media headlines and first paragraphs are designed to get your attention, period.  They are not the be all and end all of the study.  You should always read to the end.  For example, in the The Onion article, we find this quote: "Rossum's detractors are quick to point out that a high percentage of zombies in his studies are young accidental-death victims, many still in their teens, recruited from the punk-rock-fan community. Such individuals, critics charge, are too healthy and recently deceased to be reliable subjects in long-term dietary studies."  In other words, the information contained in said article might only apply to one population.  If the study is done in rats, it might only apply to rats.  Rat studies are good for promoting other research, but we don't know if this applies to humans until human studies are done.  And if it does involve humans, what type of humans were studied?  Were they smokers?  Poor college students?  Male?  Female?  Living in Italy where they have different idea of portion size than people who live in the US?  Were they put in a hospital unit a fed a certain diet for 2-3 weeks or just asked to fill out a questionaire about what they've eaten for the past 2 weeks or 2 months or 2 years or 20 years? (Seriously do you remember how many times you've eaten beef in the past 2 years?  Now what if you were a busy punk rocker zombie, or even a living person who just got out of rehab after having a stroke?)  In other words, you will always find limitations on a study, or you will find that there are enough discrepancies between the population involved and your demographic group to make it a limitation.  The more limitations, the less likely you can use it to make a health decision, as oppossed to saying "Huh, that's interesting.  Let's see what else they come up with.  In the mean time, let examine whether any other research has been done on the necessity for brains in my life."

"So SkepticRD, you obviously spend way too much time thinking about zombies, so how about a real life example?" is what you are thinking.  Well, how about this article?  In the headline, the first paragraph, and even the remainder of the article contain a lot of doom and gloom about the consumption of red meat.  And then we come to this: "They acknowledged some limitations of the meta-analysis, possible residual confounding from unmeasured factors in the individual studies, the use of self-report information on red meat consumption, between-study variations in the definition of a serving size and in meat consumption patterns, and possible publication bias." 

So, red flag number one is that this was done by drawing on a larger body of research that was already out there as oppossed to a double blind study--this means that you might not have access to research that refutes the hypotheses and that's where the publication bias comes in.  Also, self reporting, as I stated above, is notoriously unreliable as anyone who has taken Pysch 101 can attest to. (Link)  Also, variations between serving size is a big one; unless you have measured your portion on a scale several times you mostly likely overestimate how many ounces you have consumed.   Now, this study did try to adjust for age, alcohol consumption, etc (in other words, other factors that could put you at risk for a stroke), but there are still several questions unanswered.  Did they take carbohydrate intake into consideration?  Did they distinguish between pasture-raised beef and feedlot beef (which have a different fatty acid profile)?  How much of the red meat was processed with nitrates which might be linked to health problems?  In other words, SkepticRD and any other skeptics should be left with enough questions that indicate we don't have to stop eating red meat just yet.  Try to moderate portions, watch how it's processed, find other tasty sources of protein besides focusing on one thing--this is probably a good idea.  But we should look for additional research and wait before we start espousing whatever was in the headline.

Now, back to zombies.  One of the other things that interested me was this quote: "Critics also charge that a diet consisting entirely of brains would not be likely to attract many followers due to its monotonous nature. Rossum again disagreed. "  One of the statements that I have seen relatively frequently, usually when I'm reading a critique about a particular diet plan, is that diet plans that cut out an entire groups of food should be avoided or at least looked at with suspicion.  On the very surface, I agree with this statement, mostly b/c as a skeptic I want other people to view all new information with a critical eye and not just accept something based on emotion or purely anecdotal evidence.  I also agree with that to a certain extent because an eating plan is only good as long as you can sustain it after you have met your goal weight or brought your blood glucose/lipids/blood pressure down to goal levels.  Many of us eat for reasons other than survival--we eat for comfort, we eat to celebrate, we eat to socialize, we eat because a food brings us good memories, we eat because certain foods are important to us at holidays, we eat because we don't want to hurt the feelings of our host....I could go on for a while here.  Some people stil have to eat FOR survival, maybe the elderly person with heart failure didn't have a way to get to the grocery store that week and they had to eat Ramen, despite it's high sodium content, because that's what they had in the house.  So cutting out particular groups of food is often difficult from a "maintenance" perspective, particularly when you don't have a game plan going in to the holiday season, etc.  Another reason I am also suspicious of certain plans that eliminate food groups is that in some cases there is a tendency to use "substitutes" that may have no nutritional value, provide unwanted calories, or are very expensive.   Some of these plans will provide alternate sources of the nutrients that you would normally find in the "eliminated" group, some plans do not or give faulty information.  For example, one little statistic that I've read multiple times is that brocolli has more protein per 100 calories than steak.  Broccoli has ~12 grams and steak ~6-7 grams for 100 calories.  Now, keep in mind that the average adult is going to need, on average, 20-30 grams of protein per meal.  In order to get that amount of protein, you will need a little 3 ounce piece of cooked meat (deck of cards).  To get your protein requirement from brocolli, you will have to eat at least 8 cups of raw brocolli at one meal.   I'm not sure I know too many people that will want to chew that much or deal with the resulting flatulence.

Now, on another level, I actually think that eliminating certain groups of food can be beneficial.  Those of us that do have celiac disease or some other kind of digestive disorder do have to eliminate just about everything from the "grain" group unless we want to live in misery.  Sure, I could find plenty of gluten free bagels, pasta, cereal, crackers, etc, but I would wind up eating a lot of processed flour devoid of nutrition and pay a lot of money for that same lack of nutrition, and that just doesn't make sense to me from a physiological or financial perspective.  Keep in mind what I said in a previous post about how there is growing evidence that some foods do seem to have addictive qualities for some people, so some people do benefit from avoiding certain foods.   And it does also help to be a person who is willing to plan ahead, learn to cook new things, be able to set healthy boundaries with other people, and to know your limits.  Typically when people say to me "Oh, that must be so hard living without gluten,"  I look at them and say "Last night I had a turkey burger with baked sweet potato fries, fresh avocado, sauteed mushrooms and onions, fresh tomatoes, spicy mustard, a square of dark chocolate, and a Malbec.  Please, tell me how that's deprivation?"   Now, is my positive, yet somewhat snarky attitude, unique to me or is it something that can be cultivated?  Well apparently, it's a little bit of both.  Keep in mind also, that sometimes limiting our choices can be a good thing.

Take home message--always, always, always read to the end of the article.  If no limitations are mentioned, do a little more digging.  Find the actual article yourself if possible, and be very wary of self reported data.  Also, remember that limiting choices can sometimes work out in your favor, but it doesn't have to mean deprivation.

*Yes, The Onion is satire.  If you haven't figured that out, I can't help you.

Wednesday, August 15, 2012

How would you like that prepared?

People often ask me what led to my career choice and will usually tell them about how I happened to grow up around people who had an interest in what we would now call complimentary and alternative medicine (CAM).  Because I grew up in a religious community nobody employed crystals or talked about chakras (that I know of) but there was a certain amount of emphasis on using foods, herbs, and other "natural" things to heal whatever ails you.  There were still quite a few farms and gardens in existence in the area where I grew up so we didn't usually have a shortage of fresh or frozen vegetables or a shortage of recipes for zucchini!  So it doesn't surprise me that when I go to southeastern PA to visit family I hear tales of people who are trying to heal what ails them through a "raw diet" or that there is a raw foods restaurant in one of the smaller towns.  I have had an interesting time eating there but it does make me wonder:  What does the science say?

**Side bar: Now, if you really want to go down a fascinating (to me) history of CAM in the Mennonite community, do a search for "Mennonite Pow-wow doctors" or "hex doctors" or just start here.  My grandmother would also be able to tell you some fascinatingstories about children who had to drink their own urine in order to "cure" bedwetting, washing your face in morning dew to "cure" freckles, etc.  Most of these hex doctors had disappeared from the Mennonite community I grew up in, but among the more conservative sects and in the Amish there were still tales of such things going on.

First of all there are several different styles of raw diets, here is an overview in brief:
--Sproutarian Diet--The diet is mostly sprouts.
--Natural Hygiene Diet--Apparently the people who purport to follow this have many disagreements about what the diet should consist of, but apparently the commonalities include a consumption of raw fruits, vegetables, nuts, and seeds. Some will include sprouts, seaweed, and dried fruit, some apparently hotly argue against it.  A few people will also include raw milk, cheese, and eggs, and some will even include a few cooked grains and vegetables.
--Instinctive Eating (Anapsology), also called the Raw Paleolithic Diet or Sequential Mono-Eating.  Those who espouse this diet only eat one type of food in sequence and are "guided" by their senses in that changes in smell or taste change are a signal to stop eating.  Usually they consume raw fruit, raw seafood, raw meat, some raw vegetables and no dairy and/or grains.
--Essene Diet--a diet based on the Essene Gospels of Peace, which is a book published in 1937 that was suppossed to be a translation of "ancient Aramaic manuscripts discovered in 'secret' Vatican vaults." The first book contains an alternate Trinitarian viewpoint in which Jesus is named the "Master" and outlines a plan for a healthy lifestyle including water fasting, raw sprouts, wheatgrass, vegetables, fruit, and fermented raw dairy products.
--Fruitarian Diet--In this diet people eat 75% of their diet from fruit (fruit as in the common usage of the term), and might include sprouts and leafy greens.
--Liquidarian Diet -A diet consisting of only consumes liquids and juices, typically used for "cleansing" only.
--Breatharian--used to describe someone who does not consume food but gets energy from air.  Used as part of a rare practice from an obscure Tantric sect.
--Generic Raw Food Diet--Used by those who don't want to be categorized, might be vegan or contain raw dairy.  Typically needs to be at least 75% raw foods for someone to call themselves a "raw fooder." (1, 2)

In my career and in my time as a vegetarian, most of the "raw fooders" I encountered fell into the generic and/or natural hygiene diets.  Let me focus on the good that I have obeserved first (notice my use of the word observe vs. study or reasearch).   The people who follow these type of diets can do some seriously amazing things with vegetables, fruits, and nuts as far as improving the flavor and variety of what they consume.  Get bored with eating kale in a salad?  Whip out the dehydrator and make kale chips.  Tired of eating plain old almonds, whip out the vitamix and make almond mayonaise!  Gluten intolerant and missing desserts like baklava?  Whip out your food processor and dehydrator and make raw baklava!  Can't tolerate dairy and miss ice cream?  Whip out the vitamix again and make a banana whip!  In other words, it is unlikely you will be bored with the amount of vegetables and ways of preparing them and therefore unlikely that you will suffer from a lack of plant foods in your diet.

One of the major claims made by raw foodists that is a problem, however, is that all food has a "life force" and that heating food over 116 degrees kills this force.  Foods that are "alive" are best for optimum health and "dead" foods are not.  Which means...absolutely nothing.  The concept of the life force is left undefined, and if you can't define something, how can you possibly kill it in the physical world.  And the concept of optimum health is also left vague and wide open to interpretation.  In other words, no evidence.

A related claim, one that tries to sound more scientific I suppose, is that the heating of the vegetable matter and the milk (during pasteurization) kills off plant enzymes and milk enzymes needed for digestion.  Actually, the enzymes that are in the plant are for the use of the plant itself, the enzymes that we as humans need to digest the plant matter are already found in our digestive system.  Same with milk, the enzymes that we need to digest it are already in our systems (although a large portion of people stop producing lactase, needed to digest lactose, after the age of three or four years). (Link)

Another claim is that the heating of the vegetables destroys the vitamins and minerals present in the vegetables.  The people who make this claim are somewhat correct in that boiling the heck out of vegetables can destroy the vitamin C content of fruits and vegetables, but if the vegetables are steamed, stir-fried, made into soup where you retain the broth, you only get a 5-20% loss.  Sometimes cooking can actually enhance the absorption of certain vitamins and minerals as is the case with beta-carotene.  Also, in previous posts I mentioned that most vegetables have anti-nutrients which might keep us from absorbing certain items.  One example of this is the oxalic acid found in spinach--cooking helps neutralize the oxalic acid so that we can actually absorb iron and calcium. (Link).  So when it comes to vegetables, it looks like a mixture of raw and cooked would be a good thing.  Sometimes you might put the spinach in your smoothie, sometimes you might steam it, it's all good as long as you actually eat your vegetables.

Another problem with the raw vegan diets is that most people do wind up having to take a B12 supplement and supplement with zinc.  Any eating plan that requires the purchasing of supplements should raise a red flag.  Now once again, as I said in previous posts, some people will choose to follow a vegan diet (raw or otherwise) as part of their ethical code, and it is their choice, but you might want to take a supplement if you do not include any animal products in your diet.

One of the problems that I see in the raw paleolithic plan is the use of the term instinctive.  I see this as implying that paleolithic people had some sort of special knowledge about what to eat and how to eat it (which would explain some of the myths associated with the creation of food), whereas humans actually evolved eating whatever the hell happened to be around.   Chances are there were early humans who ate certain plants that were toxic, especially if their usual source of food was around, and if said humans became sick or died horrible deaths, any survivors probably tried to convey to others they shouldn't eat that.  If times were hard enough, they probably found ways to "process" whatever they found by pounding or cooking just to see if they could get something to eat that didn't taste bitter or make the eater sick soon after consuming.  Given that there is evidence of good dental, bone, and heart health among paleolithic people, apparently some people survived the trial and error long enough to live healthy lives until they were killed in a hunting accident, etc. (Link) From a modern day safety standpoint, most commercial raw meats are teeming with bacteria and parasites which are killed by cooking (unless it's rancid); even some "wild" or foraging animals have been known to contain pathogens. (Link).  Keep in mind to that the cooking of meat also makes the protein and other vitamins and minerals more bioavailable; once again I would highly recommend the book "Catching Fire: How Cooking Made Us Human" by Richard Wrangham for more information on this subject. 

Keep in mind that charring the surface of meat, eating meat that has been breaded and deep fried, or cooking in processed oils might increase your intake of potentially carcinogenic compounds.  We are just not sure how much you can take in safely. (Link)  This also doesn't mean that you can't ever enjoy sushi, ceviche, or kitfo if you like that sort of thing, but of course you are always having to put your trust in the restaurant. 

Raw milk is often illegal to buy and might also contain unwanted bacteria, make sure you trust your source.

Take home message--enjoy a variety of fruits and vegetables cooked and raw; when consuming raw vegetables make sure they are thoroughly washed.  Meats are best enjoyed cooked, if you are going to consume rare or raw make sure that you do a little homework on the source beforehand.

Tuesday, August 14, 2012

Making the best of it.

Here in Skepticville I am trying to help people make the best choices that they can while hopefully improving the knowledge about how our body works.  Unfortunately, most of us know that our food choices are not merely guided by biology and physical hunger, they are also guided by our culture, our desire to socialize, memories that we associate with certain foods, and even our desire to influence the world around us.  In the post before last I talked about how my desire to exercise good stewardship with the Earth's resources, and I guess you could also say the culture I grew up in, influenced me to become a vegetarian.  And even though I decided to make the choice to start eating meat again, I know that other people will still want to remain vegetarian for a variety of different social reasons.  I have at least one friend who gets nauseated whenever she is near meat in the grocery store related to her memories of being stationed near several slaughter houses when she was in the Air Force and other friends who are trying to undermine the facilities that treat animals cruelly.  Many of the people who choose to be vegetarian may be perfectly aware that humans evolved through the consumption of meat, and many others are aware of the problems associated with over consumption of carbohydrate, but they still want to hold true to their ideals.  At the same time, they don't want to completely sacrifice their health, so they want to find the next best way to improve their nutrition, and that's the subject of today's post.

**One more plea though, if you have celiac disease, any type of inflammatory bowel disease, irritable bowel syndrome, or an autoimmune disorder I would still strongly encourage you to rethink your vegetarianism as your digestive system may not handle a lot of "alternate" protein sources.  It's your body, your life, your ideals, but do think it over.

OK, first of all, get to know a variety of different vegetables and ways to prepare them.  Yes, I know that sounds strange that I would be telling vegetarian's to eat vegetables, but in a world of processed food one can be vegetarian and not eat a lot of vegetables.  By making vegetables take up the majority of your plate you know you can be filling up on things that add volume and a lot of vitamins, minerals, and antioxidants without giving you a huge carbohydrate load.  One of the reasons I still retain most of my vegetarian cookbooks (including the raw food ones!) is because it gives me ideas for different seasonings to add, different combinations, and different ways to prepare them besides steaming.  If you have access to purchase local produce or can sign up for a CSA or a delivery service like, you will likely get to try vegetables you haven't even heard of (and a lot of times the local farmers can provide you with new recipes).   Besides getting nutrition advantages, you will likely reduce the boredom factor and be more likely to stay on target.  I also find that washing and chopping (and sometimes freezing!) the vegetables soon after purchase makes me more likely to eat them as well.

Second, now that you're filling up on vegetables, try not to overdo the fruit and try to stick with what's in season.  Fruit does contain a lot more carbohydrate per cup, etc than most vegetables and it can be very easy to overdo it.  To help control your portions, try to stick with berries (only 10-15 gram carb per cup), or eat fruits that you have to work for/chew on like apples, oranges, etc.  If you limit yourself to seasonal fruit you will find that it has a better taste so you can enjoy your smaller portions more.  Avoid fruit juices as much as you can because it's very easy to get a carbohydrate and calorie overload!

Limit your grains to small amounts of rice (which do not have as many anti-nutrients as other grains) or grains like quinoa that actually have some protein.  You can pack a lot of calories and carbohydrate into what seems like a small amount of pasta, cereal, or bread and pretty soon you are way over your limit.  (I personally have never been successful with portion control when it comes to pasta!) Once again, keep in mind that animals evolved to avoid predators by running away, plant evolved to avoid predators by creating anti-nutrients.  In other words, that grain might actually have some B-vitamins in it, but the lectins and phytic acid in the grains are going to keep you from absorbing the nutrition properly.  If you don't appear to have any issues digesting gluten, you may want to consider sprouting and/or fermenting grains which can help get rid of some of the anti-nutrients.  Keep in mind about what I said in previous posts about some of the research pointing to the "addictive" qualities of grains; if you find yourself wanting to overeat or certain things you may not want to eat those foods very often.

Make sure your meals include plenty of healthy fats.  Eating healthy fats will make it easier for you to absorb vitamins, decrease your risk of depression, possibly decrease your risk of certain cancers, and fill you up so that you're less likely to overeat on carb-laden foods.  And it sure is tasty too!  Keep in mind that our bodies do not make two types of fat--omega-3 and omega-6, so we need to get them from food sources.  Healthy fats include olive oil, avocado and avocado oil, coconut and palm oil, macadamia oil, and grass-fed butter if you tolerate dairy.  Saturated fats like coconut oil, palm oil, and butter have a higher smoke point making them the best for cooking and they also tend to last longer without going rancid.  Flax oil can be used to get your omega-3--it's not as efficiently converted as animal sources of omega-3 but at least you are consuming it.  Don't use flax oil for cooking, however, unless you want a quickly burned icky-tasting mess. (1,2)  You also want to avoid eating refined or vegetable oils such as peanut oil, corn oil, grape seed oil, soybean oil, and/or canola oil.  Why?  Even though we need to have omega-6 fats in our diet, most of us get more omega-6 than we do omega-3 and that could actually be pro-inflammatory and increase your heart disease risk. (Link).  If you are a vegetarian who also happens to be an endurance athlete who rips through a lot of calories, adding healthy fats is another way to meet your calorie quota as well.

And finally, we will complete the meal with protein.  I deliberately left this for last since I used to hate the smarmy comments about me not getting enough protein when I was a vegetarian, and vegetarians aren't necessarily in danger of immediate protein deficiency.  You will have to work a little harder, however, to get all of the 22 amino acids your body needs, particularly the nine essential that your body cannot manufacture. (Link).  You will also likely wind up having to consume more carbohydrate to get at these protein sources, so if you have type 2 diabetes or a history of insulin resistance you are going to have very little wiggle room when it comes to consuming grains or fruit.  All that said, one of the ways to ensure that you get enough protein is to make use of whey protein powder if you tolerate dairy and are willing to include dairy in your diet.  Whey protein is more easily absorbed than some other protein powders and does contain the essential amino acid leucine which seems to play an important role in building muscle (Link).  You can also get this same high quality protein from Greek yogurt.  If you are willing to include eggs, eggs are also an easily absorbed form of protein and if they are omega-3 enriched and pasture raised that is an extra bonus.  One of the types of legumes that has the least amount of anti-nutrients is lentils; to get the most out of other legumes you can once again try sprouting (and watch the carb count).  Nuts and nut butters will also help you get protein, but before you down that whole bag of almonds (you know who you are!) you will need to remember that if you do more than 1-2 oz per day you risk getting an overload of omega-6!  Nuts also contain anti-nutrients that can bother those of us with sensitive digestive systems, so one again you might want to learn how to soak and sprout the nuts as well!

Still willing to do the work?  If so, happy cooking! 

Reading back over what I wrote it looks like I could come across as stating that no-one should ever eat grains or legumes.  Human beings are amazing in the way we adapt, and that includes adapting our food choices to our situation.   Even if it's nailed down, we will find a way to eat it if it means our survival!  And quite simply, if we removed all of things that we a recent part of our history, people would starve.  People asked me how they could optimize their nutritional intake, and I have given my answer based on the best evidence we have available.  If your body has adapted where you tolerate grains in certain amounts and you have no digestive issues with properly prepared legumes, as long as you keep doing your homework you should be fine.

Monday, August 13, 2012

It's mixed up.

As I mentioned in Sunday's post I finally sat myself down to watch Forks over Knives, and although the documentary focused mostly on the health benefits of a "whole foods plant based diet" they did lightly touch on the environmental impact.  Today's post is sort of a follow up to that but also one that
I have wanted to discuss for a long time, whether or not a vegetarian diet is the only way to go for a better environment.

One of the reasons I became a vegetarian initially was because I did think it was better for the environment.  My feelings about the environment were also influenced by growing up Mennonite and we were taught that we were supposed to be good stewards of creation and that meant not using up more resources than we had too and giving of what we had to help people who were less fortunate.  In the 1970's there was even a cookbook published call More-With-Less Cookbook by Doris Janzen Longacre that focused on using less meat, less sugar, more legumes, and even included recipes from all over the world that were contributed by people working overseas.  I would hazard a guess that this cookbook was a part of many Mennonite homes of my generation, and I still retain a copy.  You can even buy a copy on today!  In the wider world in the 1970's there was also a book published called "Diet for a Small Planet" by Frances Moore Lappe which also detailed the use of the world's resources in the raising and consumption of animals for protein.   Being the type of "throw my heart fully into everything person" that I was (aka overly zealous college student), I decided that the only way to really do this was to be a vegetarian.

Of course, one of the things I neglected to think about was that neither of the authors of this book were/are vegetarian.  When I read the updated version of Lappe's book she stated clearly in the introduction that she is not a vegetarian.  I thought that was rather weird at the time, but with my mind filled with images of land turned to dust by cattle and memories of the horrible smells emanating from a pork processing plant near where I grew up, I still thought what I was doing was better.

Fast forward several years to a time when my when my critical thinking skills had improved and I had learned to look at most things through a lens of skepticism, and I learned that it was ok to admit that I could have been wrong or partially wrong about many things.  I also realized that for whatever reason my body would no longer tolerate many of the things I had consumed as a vegetarian (first dairy, then gluten, then soy and other legumes, then nuts, ugh!) so if I wanted to take care of my own health I would have to start eating meat again.  So, I had to turn to what the research says about our food intake and the environment to see if I could find some way to balance this out.

One of things that complicated my search is that the definition of vegetarian is fluid.  I found this out when writing the vegetarian chapter for the Texas Dietetic Association manual and found out that I had to include all the various categories including pescaterian (eats fish regularly) and flexitarian (eats animal products based on the situation).  And there are also people who merely eschew animal products for animal rights reasons and may or may not still eat a lot of processed foods, and people who eschew animal products and also eschew anything processed, and people who eat raw only, and people who are ok with cooked food, etc.

One of things that is fairly common among most of these groups (except for those that eat mostly raw) is that there is typically a higher consumption of soy, legumes, grains and grain products (e.g. seitan).  If one is not careful where one is purchasing said products, chances are the person is consuming food that is the product of large scale industrial agriculture which can be destructive to topsoil and surrounding land.  (Link)  So if someone's diet relies quite a bit on grains, including whole grains, and things derived from grains, it is going to be hard not to feed into harmful practices.  Also, there is a commonality among groups regarding a reliance on soy and other legumes.  Depending on how much one relies on soy and meat subsitutes derived from soy, you might actually be using more energy to produce said products and more farmable land that could be used to locally raise livestock.  There is also a use of energy if you have to import things as is the case for the UK.  No one is denying that raising grain fed livestock in a feedlot environment is also destructive, but the choice to move to an exclusive vegetarian diet may not work out either. (Link).

One also has to keep in mind that the interaction with food and the envioronment is quite complex.  For example, the University of Chicago did a study that indicated that a vegetarian/vegan diet did produce fewer carbon emissions. (Link) However, reducing carbon emissions isn't the only thing that you have to consider when it comes to the environment, you also have to consider how the land is being used.  Sometimes land that cannot be used for crops could be used to pasture animals, and the animals in turn can help provide fertilizer for the crops.  A study released by the Cornell University demonstrates that a mixed farm (where the crops and animals work together so to speak) provided the most efficient source of land use (Link).  Another book that covers what life on such a farm is like and how we might expand this in is the highly entertaining book by Joel Salatin Folks, This Ain't Normal.

So it looks like the evidence is pointing too...a more complex problem that cannot be solved only by going to a vegetarian or vegan diet.  There is definitely more evidence that points us away from overconsumption of grains and processed grain products both from a health standpoint and to not influence the erosion of topsoil, but one definitely doesn't need to go the other way in to complete disregard for where your sources of animal protein are coming from or to eat protein without any regard for how much your taking in.   I would also say that we have to consider people's individual health history when making a decision.  For me, choosing to go back to a vegetarian diet would result in some serious nutritional deficiencies and intestinal distress, other people, as listed in the movie discussed yesterday, are doing well on a mostly vegetarian diet.  And if you are choosing to "moderate" remember this post, it's not moderation unless you have some way to quantify what and how much you're eating.

Sunday, August 12, 2012

Fork over that Knife

Well SkepticRD has finally got around to watching the documentary film Forks over Knives.  As mentioned before I was a vegetarian for about 16 years and in that time made friends with a lot of vegetarians so I knew this movie was a big deal in a lot of people's lives when it came out.  Since I've been asked about it, I finally had to sit down and watch it.  I knew I had plenty to talk about after the first half hour of the film was over.

First, I think the makers of this film were counting on people not being aware of their evolutionary history.  Our brains and our bodies could not have evolved into what we are today without the consumption of meat. For most of human history humans operated as a hunter gatherer society, meaning we ate only animals that were available and the vegetable matter that we could find (and sometimes some seasonal fruit and nuts) and grains and legumes simply weren't available.  Agriculture has only been around about ten thousand years, which is a blip in our evolutionary history.  Yes, prehistoric people may have had a shorter life span ON AVERAGE, but this average comes from people dying from being gored by an animal they were hunting or died in childbirth, not from heart disease or cancer.  So, given that our bodies evolved with a heavy influence on animal protein, how could the consumption of animal protein by itself lead to heart disease and diabetes?  (1, 2, 3,)  I would also highly recommend the book Catching Fire: How Cooking Made us Human by  Richard Wrang (not to be confused with book #2 in the Hunger Games series, ahem!).

Second, the amount of false equivalencies that were being drawn was astounding.  Notice that most of the people who had poor diets mentioned that they were living on caffeine and sugar, or donuts and fast food, or sweets and meatball subs from Walmart, etc.  In other words, their diets likely included meat, probably dairy, and very likely way more sugar, white flour, trans fat, nitrates, sodium, etc that the human body has evolved to handle.  So very likely this contributed to their health problems like heart disease and diabetes.  These people were very likely also consuming a lot of nutritionally devoid calories through their sugar, processed oils, white flour, etc so this probably contributed to their obesity.  So, if people cut out their trans fat and PROCESSED oils, white flour, added sugars (including high fructose corn syrup), low fat milk, and PROCESSED meats and ate more vegetables and fruits (plants), they will get healthier.  But there that doesn't mean they had to cut out all meat (what we evolved on) along with the sugar and white flour to get the same health benefits. Notice the gentleman from China grew up eating meat, just not as much as he did when he moved to the United States.  So once again, there is no good evidence that meat needs to be completely thrown out.

Third, the research that presented was highly flawed and the way it was presented screamed of bias. Forcing rats to eat large amounts of casein, which rats have not evolved to eat, and they developed cancer?  Not surprising.  And the aflatoxin they were sensitive too?  Found in corn, wheat, peanuts, and pecans--all part of a vegetarian diet.  Maybe we should think about removing all the the problems?  Also, human beings are not rats.  Animal studies can give us something to research further, but we can't draw a direct equivalency to humans.  Also, the higher incidence of liver cancer, in children in Asia that was mentioned?  They forgot to mention that one of the foods introduced to Asian countries during and after WW II was processed meat, usually in the form of Spam.  Chances are, those more affluent families had more access to this processed meat as opposed to the unprocessed meats the parents and grandparents would have grown up on, but this variable was not mentioned.  And I really started yelling at the TV (again) when he started talking about the reduced deaths from heart disease in occupied Norway.  Sure less people did die from heart disease, but there was no mention of all cause mortality.  In other words, people may not have died from heart disease, but they could have died from oh, lack of food in general, lack of access to medical care, or possibly being shot or send to concentration camps by Nazi's? But we can't tell, at least from the information given here.

Fourth, there was some information that was deliberately misleading about heart disease and cholesterol.  They were correct in that cholesterol is a vital component of our cell membranes and that humans do also produce cholesterol.  But the cholesterol circulating in our blood stream does not come from dietary cholesterol.  Forgive me for greatly simplifying a highly complicated body process here, but basically our body is smart enough to decrease cholesterol production whenever we eat it.  The notion that we need to decrease dietary cholesterol if our blood cholesterol is high is based on flawed research surrounding the fact that cholesterol deposits are found in arterial plaques.  And how does the cholesterol get there?  If we eat in such a way as to elevate our insulin levels (i.e. take in too big of a load of carbohydrate), or eat too much trans-fat or too many omega-6 fats, or don't get enough sleep, or all of the above, we are increasing the chance of setting off an inflammatory process in our arteries.  That inflammatory process basically stomps all over the inside of your arteries, and your body will have to make more cholesterol to try to plug up the potholes so to speak.  So, remember how all the people with poor diets were eating a lot of added sugars, white flour, etc?  And not getting enough sleep in some cases?  Maybe that could have contributed to the problem?  Also, I felt this film was dismissive in it's treatment of protein.  It is a vital nutrient, and people who don't get enough will be malnourished.  Sure, some people consume way more than they need, which might have negative consequences as far as your cancer risk, but that's not a reason to dismiss it (Dose determines the poison people!).  And of course you can get protein on a vegan diet if you are able to eat legumes (including soy) and nuts, but these are not as readily available to us as animal proteins are.  Remember your evolutionary biology again.  Animals evolved to avoid predators by running away.  Plants can't do that, so they tried to ensure the survival of their species by forming a group of chemicals collectively call anti-nutrients that can make the predator sick (like how I get when I eat gluten!) or have to go to a lot of work for the body to get to the nutrition (like all the work that goes into preparing beans so you can chew and digest them).  Now, humans wind up being quite resourceful in what they will and can eat to survive, but they may not be achieving better health!

Fifth, towards the end of the film we get the classic red flag in my book, where the proponents of this diet get to talk about how they were persecuted for what they were doing and how all the money from Big Pharma and Big Agra are working against them.  SkepticRD will be one of the first people to tell you that the Food Guide Pyramid, etc was also not based on good science, which will be the fodder for a whole different blog post (I have to keep you reading right?).  However, using the "everybody is persecuting me" argument is not good science.  Sure, there are legitimate scientists, like Louis Pasteur who were dismissed initially and later recognized for their contributions, but there are also people like Andrew Moulden who deny germ theory.  If people are not being allowed to conduct legitimate research I think that is a problem, but it doesn't mean that people are somehow right because they are a lone wolf.  And the woman who was asking to be taken off her diabetes medicines?  That's a question I get asked a lot.  If someone's blood glucose levels are now running too low unless they are eating constantly, the physician would be going against their "do no harm oath" if they didn't start removing medicine or insulin.  Same thing with blood pressure medicine.  If your blood glucose levels are running within the correct range and you tell your doc you want to come off the medicine, of course they are going to be hesitant, not because they are all in the hands of Big Pharma but because as good scientists they don't know if just the diet is controlling it or the diet and medicine together.  A more legitimate question would be to ask "Can I go off my medicine for the next two weeks and carefully monitor my blood sugar and/or blood pressure?"  That way you are getting closer to science and everyone can be happy.

This film did touch a little bit on the environmental impact of vegetarian eating and about what happens to the animals in our food system, and that it definitely worth addressing, but I will do a follow up blog post to this one to address that.  For now, let's just say a vegan diet might not help like how we thought.  If you do not want to eat animals at all, and I can understand why some people don't, that is fine, but you still don't really want to use flawed research to support your position, do you?

Now, I know that some of you in reader land might be thinking, "So is SkepticRD advocating for these people to go back to their previous donut/fast food/hot dogs/no vegetable diet?"  Why would I do that?  Why would any legitimate health care person not be happy that someone changed their lives for the better by taking responsibility for what goes in their bodies, particularly when several of the changes that they made (like avoiding processed foods) were based on good science?  But what if someone did want to start including some pasture raised beef or chicken or wild-caught fish back in their diet (or never wanted to give it up in the first place)?  What if, like me, they wound up intolerant to vegetarian protein sources such as legumes (including soy) and nuts? Could I tell them, that based on the use of good reasearch and knowledge human evolution that they need to avoid it?  No, I cannot, not based on most of the information presented in this film.

I know, you're waiting for my take home message--yes, cutting out all the processed stuff and eating more vegetables is a good idea and there's research to back it up.  Cutting out meat isn't necessary to lose weight and lower your cholesterol, inflammation, risk of heart disease, or risk of cancer according to better done research.

Thursday, August 9, 2012

What is this moderation you speak of?

“Even junk foods can be part of a healthy diet  as long as they are consumed in moderation.”
How many times have you read that?  SkepticRD has lost count, because quite frankly, this phrase, and closely related phrases, drive me up the wall.  Why, because the phrase “consumed in moderation” has got to be one of the most vague non-guidelines that I have ever come across.  If you haven’t figured it out, SkepticRD likes to shout at the computer or whatever it is I’m reading when something registers as “bad science” so this is another phrase that has me yelling: “What the hell does that mean?  Who came up with that?”  along with a few other colorful metaphors.
Here’s my opinion, in brief, about how this phrase came about.  Back in the day, Dietitians who focused on education had the reputation of being akin to Catholic school ruler- slapping nuns—“eat this way in this manner or you will suffer the consequences.”  So, of course many people went to see the diabetes educator out of guilt and with a certain amount of dread, then came away with a plan that seemed impossible to the average person (seriously, who eats like this?).  Soon they would feel guilty because they would follow things for a while but then “cheat” and try to do some sort of penance, etc.  This whole procedure caused people to fall into a constant cycle of gain/lose weight or ok blood sugar control/poor blood sugar control, or they would just flat out give up and live a life of hedonic eating.  (Or, to stay with the lapsed church goer theme, only “do things right” when they thought somebody else was watching, “No really, I try to eat right!  At least twice a year!”) 
So, the group of people who decides these things decided that we as health educators were being too harsh.  “People need to have more freedom to fit all kinds of food in, all foods can fit!”  So we  started finding ways to help people fit in their cookies and potato chips and orange juice all in the name of changing our counseling sessions to more of a collaborative effort from a ruler slapping one.  (Side bar #1: Don’t get me wrong, I think collaboration is a wonderful thing.  Adults don’t want to be told what to do, especially when the person is about 20 years their junior.  Sharing information is the way to go, if you are sharing information that can actually work).   I think the relationships between diabetes educators and their patients did improve somewhat  (although sadly I have no objective data), but I noticed something else.  People still weren’t losing weight and keeping it off the way they wanted (or the way I hoped, for that matter), and people were coming to me all the time with statements like “I ate oatmeal in the morning, my blood sugar shot up.” Or “Every time I eat [insert fruit here] my blood sugar goes sky high” or “Who the hell wants to eat 10 potato chips?” (Once again, there were often a few more colorful metaphors thrown in there).  So, I started thinking to myself, “I want people to have choices.  I don’t want people to have to give up everything they love.  But what if this approach is not working?  What if some people simply cannot eat certain foods on a daily basis and keep their blood sugars under control or lose weight?”
(Side bar #2: SkepticRD was not always a skeptic.  SkepticRD periodically blushes at some of the things I used to accept on blind faith, and someday there will be a “tell all” blog post.  But let’s just say my passion for  helping people find something that works has improved my life as a skeptic).
So, what does a good skeptic do when faced with years of doing something that isn’t working?  First, humility and honesty with myself comes in.  I had to say “I might be wrong, and what matters is that I correct it.”  Second comes humility and honesty with others, meaning I had to say “Look, here’s how we’ve been doing things, it’s not working, let’s try to find something together that works instead of running around in circles.”  Third, is to start looking at what the science says, even if I didn’t like it.  And this last one is really, really hard.  When my emotions are running high on a topic, it’s really easy to dismiss something instead of reading it further, particularly when the author of the piece is not writing in a very science based way.  Fourth, one has to try to try it out in the field, so to speak, and keep trying even in the face of opposition.
One of the things I found through my digging was that too many choices can actually be detrimental, which was covered in a previous post..  In brief, when someone is presented with too many choices it can seem overwhelming and people will give up.  One of the other things that I found through my inquiry is that there has been some interesting research done in the past few years on the addictive qualities of certain foods (Link).    Of course, there is still a lot of research to be done on addictions in general, particularly why some people seem to be more prone to addictions and/or relapses than others, but it was enough to at least raise some red flags as far as the practice of “moderation” is concerned.  And I also thought about what people would be missing by not working in their daily ice cream or whatever it was; and from a nutrition standpoint, the person wouldn’t be missing anything.  Of course, we all eat for reasons other than hunger, and it likely wouldn’t be easy to give up certain foods, but then looking for the easy way out can cause its own problems. 
So, when people ask me if a certain food is something they “can have,” I remind them that they are free to make their own choices, but they also have to pay the consequences, whether it be high blood sugar, needing more medicine, weight gain, etc.  Second of all, I ask them to honestly consider whether or not they will truly and honestly be able to eat only 10 tortilla chips and be content.  (Boyfriend of SkepticRD can do this, but many of us, including SkepticRD, just want to eat the rest of the bag).  I also ask people to truly and honestly consider how they feel the rest of the day after they eat that food—any digestive issues, increased hunger, increased fatigue?  If I can get empirical data such as blood pressure, blood glucose, weight I might ask them to check these more often.  Some people acknowledge, “You’re right, if I eat one slice of bread I will eat it all day.  If I take 4oz of OJ my blood sugar goes sky high.”  And all of that information likely adds up to— yes, there are going to be some things that you just cannot consume on a regular basis (or ever) and still meet whatever your health goals are.
(Side bar #3: Acknowledging that you cannot keep certain foods in the house or have it brought to the table is not a sign of weakness.   You are merely acknowledging that there are certain foods that affect your body adversely, and you know there is some evidence that they might affect your brain adversely as well.  There is no shame in that).
Because the concept of moderation is so vague, there are a lot of health education related folks that have tried to find some way to quantify this.  I have heard everything from “have one reward meal per week” to “try to eat the way you ‘should’ 80% of the time” to “pick one day a week to eat whatever you want.”  Sounds really good in theory, but there really haven’t been any studies that I can find that actually back this up, particularly over the long term.  And once again, you have to know your limits.  For example, let’s say you’ve been really “good” for several weeks on your new plan, watching your carbohydrate intake from both your food and drink, etc, and then you decide to have a night out at the pub where you consume most of the appetizers available and several of your favorite beers.  The next morning, you have the worst hangover of your life.  Some people, might consider the nausea, vomiting, and headaches worth it.  Other people, might decide that it wasn’t.  Also, some people, like me, find that if they overdo the tortilla chips that it will take a few days at minimum to regulate my appetite.  So yes, moderation on certain things, even at the nebulous “80%” may not work for everyone, particularly in the beginning.
If you still think that some things can be consumed in moderation, be prepared for me to ask, “Really, how much is that for you?”  And if you tell me you can have one teaspoon of honey in your one cup of tea in the morning, AND you are done with your sugar intake the rest of the day AND you have no adverse affects, I will thank you for providing a quantitative answer.  If you tell me that you have one teaspoon of honey in your green tea, AND you drink about 3 to 6 cups per day, AND you complain to me that you can’t lose weight or keep your blood sugar down or that you’re always hungry, then we will have to have a talk about reality.
(Side bar #4:  Here is where the food diary can come in handy—whether it’s paper and pencil, use of a spreadsheet, software on your desktop/laptop computer, or an app on your smart phone.  You might be surprised at how hard it is to be moderate).