Friday, October 26, 2012

Selling carbohydrates

As a diabetic educator, I often get a lot of questions about carbohydrates, more so after my last blog post, and a lot of the questions have to do with both the terminology that is employed when describing them and how much a person should eat.  I hope to explain some of the questions that I get, and also deal with a few of my pet peeves in the process.

1. "Are complex carbohydrates better than simple carbohydrates?"  Typically the subtext of this question is really "Are complex carbohydrates better for my blood sugar than simple carbohydrates?"  To answer this question, I want to explain a little bit more about what "simple" vs. "complex" means when used in front of the word carbohydrate.  A simple carbohydrate has only one sugar molecule or two bonded together (think about a necklace with only one bead on it, or a strand of single beads strung together).  A complex carbohydrate has three or more sugars bonded together (think of a strand of different kind of beads woven together).  Now think about dipping either the simple necklace or the complex necklace in acid; both of them are going to break apart at about the same rate.  When a simple or complex carbohydrate gets hit by amylase, it starts breaking down at a similar rate.  So the term "simple" vs. "complex" is merely a description of the chemical structure, period.  It really doesn't tell us about how quickly something affects your blood sugar.
Now, where this gets confusing is that certain carbohydrate foods, often the "complex" ones, may be higher in fiber, and they also might take longer to consume, which MIGHT impact your blood glucose levels.  Fiber slows down the emptying of your stomach, so in theory certain foods might take longer to get to your intestines and therefore your blood stream.  As far as consumption time, think about the difference between four ounces of orange juice versus a small orange.  Most people can knock back that amount of OJ in a couple swallows--so you get 15 gm of carbohydrate in your system pretty fast.  With that orange you have to peel it, chew on it, spit out the seeds, oh, and you also get some fiber to slow down the emptying of your stomach.  That orange is still going to impact your glucose levels, but you might see a slower rise.

2. "But I have diabetes, and I was always told that I needed to consume 'fast acting carbohydrates' when my blood sugar is low."  Once again, the simple vs. complex terminology is really only a description of chemical structure.  A "fast acting" carbohydrate is something that you can ingest quickly with a minimum of chewing and swallowing, that's all.  So, if someone with diabetes (who takes medication or insulin) has a blood glucose level below 70; they need to stop a dangerous situation from getting more dangerous--they don't need to be chewing on a sandwhich or eating any fiber or fat to slow down the emptying of their stomach.    That's why someone having hypoglycemia (aka low blood sugar) is normally told to drink four ounces of juice, or half a can of regular soda, etc.  Now, every person who has had Type 1 diabetes (or Type 2 treated with insulin) for a long time will have their own "favorite" for treating a low; I have had some people tell me saltine crackers work the best (no fiber, can chew on several at once), some people tell me chocolate bars (although this is not normally reccommended because of the fat content), some people prefer to use the manufactured glucose tabs or gels for convenience.   Each person needs to figure out what works best, but you don't want to confuse "simple" with "fast acting" necessarily.

3. "I've heard them talk about 'good carbohydrates' on TV/the radio/the internet.  What are they?"  Basically if the term "good carbohydrate" is used in a commercial or on the front of the box, the only thing it means is "We are trying to sell you this product."   After I give that answer, I will usually give my definition which is twofold.  Number one, that food is only "good" if it fits within your carb/calorie budget.  If you are like yours truly who needs to keep the carbs to no more than about 30 per meal, then a plateful of pasta is way over that.  In other words, some foods like pasta/bread/rice tend to have a high caloric density--by the time you eat a portion that fits your budget you wonder where the rest of it is!  So that's why some people give up certain foods because they want more volume.  Number two, does that food have anything good for you?  A piece of fruit will give you fiber, lots of vitamins and antioxidants; whereas two Oreo cookies will give you.....two Oreo cookies.  So that piece of fruit could be considered a "good" carbohydrate, but only if you eat one piece, etc.  That sweet potato might be a good carbohydrate, but not if it's covered with maple syrup and marmallows and margarine (you are all horrified to realize this, I know).

4.  "What about the glycemic index?"  The glycemic index ESTIMATES how much each gram of available carbohydrate (remember about subtracting the fiber) in a food raises a person's blood glucose level after you eat and compares it to the impact of pure glucose.  On this scale glucose has a glycemic index of 100 and other foods all have a lower glycemic index.  Keep in mind, however, that the GI can be affected by a lot of different things, like how well something is cooked, the ripeness of the fruit, what other foods you are eating with the particular food of note, and even the acidity of the overall meal.  For this reason, some diabetologists recommend that people forgo the GI and instead insist that each person with diabetes do extensive testing of their own blood glucose levels to see how different foods and combinations affect them (I tend to be in this camp as well). 
For people who are in that pre-diabetic state (or who have a family history of insulin resistance and are trying to be careful), you probably aren't testing your blood glucose; it wouldn't hurt you to look at the GI because a lot of the foods lower on the scale tend to be richer in nutrients--but not always, and there are some foods, like watermelon, that actually have a lot of nutritional value!  And one of the other problems I have noticed is that when people see something has a "lower" GI (like Dreamfield's pasta), they tend to (you guessed it) pig out on it, completely forgetting that the AMOUNT you eat is just as important.  At that point it would be more useful to consider the glycemic load (GL), which takes portion sizes into account.  For example, one of the foods that people have traditionally shied away from when they told they are diabetic is carrots, because they have a higher GI.  What they don't know is that the GI was established by feeding healthy individuals 50 grams of available carbohydrate, which for carrots equals about a pound and a half of carrots.  So if one uses the GL, you could eat a carrot, maybe make some carrot fries, but you probably don't want to eat the whole bag of baby carrots in one sitting.  Once again, you know who you are.
Side note:  Typically health care people have shied away from recommending the GI and the GL because it's "too difficult" to follow, and I wouldn't use this with my elderly patients who have trouble remembering to eat, let alone calculating out GL.  Normally, however, my way of thinking says "get all the information and decided for yourself whether or not you can follow it."

5.  "Do I need carbohydrate foods to survive?"  Here is where we start playing with semantics.  Technically, we could get what we need nutrient wise from eating protein, healthy fats, and vegetables and we could survive quite well.  Typically when dietitian's get asked this question, however,  they usually say "no" and start pointing out all the nutrition deficiencies you can wind up with.  For some people it's because they are still suspicious of lower carbohydrate plans despite evidence pointing out that they can be beneficial, but for others it's because you work everyday with people that have the best of intentions to eat plenty of vegetables and vary their protein sources (and even include organ meats!), but they just don't do it for whatever reason.  If you have already achieved a varied diet that doesn't include starches and don't even miss bread, etc, I think that is wonderful.  The rest of us, however, would really like to eat our tacos in an actual corn
tortilla sometimes and still keep our calories and carbohydrates under control, and I think as long as you are meeting your health goals you are fine.  I guess you could say some of need carbohydrate for our mental health more than anything, and I happen to like variety.  (I actually had a lot of fun reading about The Aboriginal Eskimo diet), but then I'm weird like that.)

6.  "Speaking of mental health, is it ok to purchase the low carb pasta, etc?"  Maybe.  I've given some tips for making that decision in a previous post.  Spending excess money and ultimately consuming more calories is something that I have noticed to be a big problem in my practice, however.

7. "How much carbohydrate should I eat."  I knew that was coming.  First of all, the amount you can tolerate is going to depend on your metabolism, so if you are a blood sugar tester, test after meals for a couple weeks to see what you can handle.  Second, keep in mind that we as human beings are a pretty hardy bunch, if you go one gram over your meal limit you will probably be ok.  Third, some people start testing their urine for ketones to see if their intake of carbohydrate is low enought that their body is burning fat for energy as glucose is no longer a readily available source of energy.  (***Warning. Warning. Warning.  I am talking about KETOSIS which is a normal function of the body when glucose is not readily available.  I AM NOT TALKING about KETOACIDOSIS which is severe ketosis in the presence of an insulin deficienciency and elevated blood glucse that can be deadly to a person with Type 1.***)  Anyway, so here's the ballpark, since you asked so nicely:
If you have a lot of weight to lose or you are a person with Type 2 diabetes who needs serious blood sugar control help: 0-50 grams of carb per day.  You probably don't want to stay here more than two weeks as you start depriving yourself of the good things in fruits and vegetables.
If you're more in that "I've got to lose some weight" or "my blood sugar control could be better": 50-100 grams per day.  You actually get to work things like fruit, vegetables, and other tasty and nutritious things in here.  I find it a little easier to stay here.
If you are ok with your weight and/or blood glucose control but you want to stay healthy (or have a history of insulin resistance): 100-150 grams per day.  Any more and your calorie intake might start creeping up or your blood glucose might start acting funny.
***Remember, these are ballpark.  If you have already found you need to stay <100 grams per day to keep your blood glucose under control, good for you.  If you are a serious triathlete, you are probably going to need more.***

Take home message--The amount of carbohydrate you can consume and still meet your health goals varies by individual.  Take care to watch the amount and the nutritional value of what you are getting.

Wednesday, October 24, 2012

Label reading: Carbohydrate Edition

Those of you who have been reading my blog have probably realized that I am very big about not taking foods at face value.  If the product that you are thinking of purchasing has a food label and a list of ingredients, I really can't think of any legitimate reason why you would put that food in your shopping cart (in "real life" or online) without first doing your homework.  Of course you also have to know what you are looking for, and one of the main questions I get is about how to make sure you are counting the amount of carbohydrates in that product correctly.

First of all, you need to make sure that you look at what that the serving size of a product is.  Fortunately these days most of the serving sizes come in what I call "practical" measures:  measuring cups, measuring spoons, x-number of crackers, etc.  All the information on that label is for 1 SERVING OF THAT PRODUCT.  Now, when I used to teach classes I would always get a bunch of eyeball rolls as far as "Oh, who is only going to eat 10 chips, etc," and I had to remind people--No one is holding a gun to your head to eat that food period, and therefore no one is holding a gun to your head to only eat one serving.  That serving is a unit of measurement, nothing more, nothing less.

Opinion: Personally, I would rather see the nutrition info for the whole package on a lot more products, so that way the amount of calories, carbohydrate, etc for that whole bag of organic potato chips (You know who you are!) is staring you right in the face.  It might also influence people to think ahead a little bit more, as in "Ok, if I only get 1/4 of this bag out and put the rest away, then I will eat less" rather than "Whoops I ate the whole bag while I was absorbed in the newest internet cat video."

Once you have figured out the serving size, either by using the company's serving size or by looking at the whole package and dividing up into your own serving sizes, you can look at the carbohydrate amount.  The "Total Carbohydrate" on the label is the sum total of ALL the different types of carbohydrates found in that product.  Some carbohydrates might be in the form of what is commonly called "sugars," those sweet tasting substances composed of carbon/hydrogen/oxygen that form themselves into monosaccharides (the most basic structure of sugar) and disaccharides (to monos combined).  Some of the total carbohydrate might consist of what is commonly called "starches," those "pasty tasting" substances formed when a bunch of monosaccharides bond together to form a more complicated structure (polysaccharides).  Some carbohydrates come in the form of something commonly called "dietary fiber," which are polysaccharides that you don't digest.  And many items advertised as "sugar-free" or "Low-carb" may contain another type of carbohydrate called "polyols" or more commonly "sugar alcohols" which also have a sweeter taste.

Those of you who enjoy chemistry probably want me to talk more about the structure of these, those who aren't as familiar probably have glazed eyes about now.  What it boils down to is this--sugars and starches are digested/absorbed by the body and provide calories and blood glucose.  Fiber is not digested/absorbed and does not provide calories or affect blood glucose.  Sugar alcohols--it depends, more details later.  What you want to find is the AMOUNT OF ABSORBABLE CARBOHYDRATE PER SERVING.  If certain things aren't digesting, you don't need to worry about the impact on your blood sugar or that they will be providing calories

So let's say you look at a label that has the following:
Total Carbohydrate         20 gm
         Sugars                     3  gm
         Dietary Fiber           5 gm
         Sugar Alcohols        4 gm

First we'll find the total carbohydrate-- 20 gm.   Then you might look at the sugar--but we know now that sugar is absorbed, so it's included in the 20 gms, so we can just ignore it.   Next you look at the fiber--you know that fiber is not aborbed, so you substract it (20 - 5 = 15) and you are now down to 15 grams of absorbable carbohydrate.  Now you are ready to look at the sugar alcohols, and here is where the fun begins.

There are actually several different type of sugar alcohols, and each one has slightly different caloric content per gram and a slightly different impact on blood glucose.    Typically the amount used per serving is small enough that you can do the same "math" for most of them--you look at the grams of sugar alcohols, DIVIDE the number in HALF, then substract what you get from previous number  (4/2 = 2 gm,  15 - 2 = 13 gm). 
The one exception to this rule is if the sugar alcohol is erythritol, this one is really not absorbed so you just ignore it.  I found this chart gives a good list of the most common sugar alcohols and will also give those of you who want to do more precise calculations the info you need.

In summary:
1. Find the total carb (20).
2. Ignore "sugars."
3. Subtract the dietary fiber (20 - 5 = 15)
4. Divide the amount of sugar alcohols in half (4/2 = 2)
5. Substract the sugar alcohols from your answer in #3 (15 - 2 = 13)
6. You count 13 grams toward your carbohydrate budget if you eat that food/that serving.

And you know what's really fun?  When you find a low carb/sugar free product, do all the math, compare that serving to an equivalent serving of the original product.....And you find there is only a one gram of carbohydrate difference.  Sometimes you might find significantly less carbohydrate in the "other product" but you might actually pay double the price per product.  At that point you have to start thinking "Is there any other nutritional value I might get from this?"  (Often the answer is no, particularly for processed foods).  You might also want to ask "Can I make this myself and save a few pennies?" (Often the answer is yes, particularly for items you feel you "have" to have for whatever reason).

Take home message--always read the label and ingredients, and do the math, before you make your decision.

Tuesday, October 23, 2012

Vitamin Water Zero Benefits

At one time human beings could only satiate their thirst with water.  In the past ten thousand years, however, some other beverages have arisen that have challenged water as our main thirst quencher, and currently there are beverages out there for sale that mention "water" in their title.  Of course just mentioning water in advertising makes us think of the satisfaction of having our thirst quenched, but are these beverages really worth it?  I was asked to talk about Vitamin Water Zero specifically, so let's see what this can and can't do for us.

Side note: For an entertaining and informative view regarding how man-made beverages have influenced and been used in the history of the human race, I highly recommend the Book A History of the World in Six Glasses by Tom Standage.

First of all, one of the things I didn't realize was there was more than one variety of Vitamin Water Zero, but a quick trip to their website indicates that there are 5 different varieties and soon to be a sixth.   And one of the other things I've noticed is that the labels can be a little confusing at first.  For example, let's take a look at the label for Vitamin Water Zero Go-Go.  First note the serving size and servings per bottle--the serving size is 8 oz, and there are 2.5 servings per bottle (20 oz bottle).  (In my experience--and it is my experience, I haven't conducted a true study!--people drink the whole bottle over the course of a day or a much  shorter period of time!)  Now look at the carb content, which is four grams per serving, or ten grams for the whole bottle.  Normally carbohydrates contain 4 calories per gram, so if there's four grams of carb per serving, there should actually be about 16 calories per serving and about 40 calories per bottle.  Why the discrepancy?  The answer lies in looking at the ingredients.   One of the ingredients is erythritol, which is a a special type of carbohydrate called a sugar alcohol.  Sugar alcohols typically only contain about two calories per gram of carbohydrate, but erythritol is even more unique in that is contains only 0.24 calories per gram, and labeling regulations in the US say that this can count as zero calories.  If you really wanted to do the math correctly, you are actually getting 2.4 calories for the whole bottle, but considering a twelve ounce can of regular Coke would give you about 140 calories, I'm not going to be terribly worried about the calorie content.  Eyrthritol appears to be safe also, so I am not worried about that either.  I am worried, however, about people drinking things without reading all the ingredients or learning more about said ingredients! 

As far as the vitamin supplementation that one can get through these products, I covered the pros/cons of supplementation in this post.  Unless you are known to be deficient in something, supplementation won't help you.  If you already make a point of eating a variety of vegetables, some fruit, and a variety of protein sources, you are going to get all the vitamin C, B-vitamins, etc that your body needs to function and the little bit of extra isn't going to give you extra energy, or fight off a cold, or basically do anything it subtly or not so subtly claims it does.

Now, there are some people who just like the taste of something other than plain water.  At that point I just remind people that it's their money and they can spend it how they want, but they might want to try plain sparkling water with lemon, lime, peppermint oil, etc for something that's a little cheaper.  I have also had some elderly patients with dementia who have developed a dislike for water for whatever reason, and using the sugar free flavored waters actually helped them want to drink more.

Take home message--don't expect to get anything other than expensive urine from Vitamin Water Zero.

Tuesday, October 16, 2012

Diet as Fountain of Youth?

October is Vegetarian Awareness month, and just like with any awareness month I find all sorts of articles on that topic popping up in my various news feed designed to catch my eye.  One article that caught my eye was this one: Eat Vegetarian, Live Longer.  Some people see the fountain of youth; I however, am skeptical, and as an educator, I see this as a great opportunity to talk again about reading articles critically as outlined by our friends at Double X Science.

1. Ignore the headline.
"Ok, you've got my attention, now I'm going to ignore you." Check.

2.  Basis of of the article?
It's original research, but since the study hasn't been concluded yet, it hasn't gone through peer review, nor have the authors drawn up any conclusions.  Observations only at this point, so we can say "Huh, that's interesting, we can keep the study going, but we can't start making changes just yet."

3.  What words does the article use?
Words like risk and association appear to be the favorite here.  Once again, correlation does not equal causation. 

4. Original source of information?
Published as preliminary findings, not a completed study.  Once again, this research still has not had time to go throught the peer review process.

5. Remember that everyone involved in what you're reading has some return in what they are seeking.
Loma Linda University is associated with the Seventh Day Adventist Church which has advocated for a vegetarian diet for years; of course they want to find reasons to continue to advocate for this.  At least they are making an attempt to study this from a scientific perspective.

6. Ask a scientist for clarification, we love to talk about science!
Problem number one, they are using the infamous food and lifestyle questionnaires, which, as I have mentioned several times before, are very unreliable.   Second, the Adventists also advocate for lots of other healthy behaviors such as not smoking, etc, which may or may not play a bigger role than the diet, or might cause a synergistic effect; we just don't know.   Third, our longevity seems to rely heavily on our genetics (Link), and since people tend to choose the religion of their parents, there may also be a genetic component at play here.  Fourth, I would also like to know what other parts of the diet they are comparing other than the meat vs. non-meat.  Is that the only difference, or are the meat eaters also eating a lot of sugar, not eating as many vegetables, not exercising as much, eating too large portions in general, less motivated to take care of their health, and so on. 

Take Home Message--Doesn't look like we've found the fountain of youth just yet.  If you are a healthy Seventh Day Adventist who happens to be a vegetarian, there doesn't appear to be a reason to stop.  If you are not Seventh Day Adventist, and/or you stop eating meat but don't change any other health behaviors, and/or you don't have the right genetics, changing your diet likely won't help you live longer.  Could we all benefit from the not smoking, eating more plants, exercising, moderating our portions, most likely.

Monday, October 15, 2012

Cold Squeeze (you out of your hard earned money)

As a follow up to my vitamin C bombing post I decided to talk about another common "natural" cold remedy that usually starts circulating about this time--zinc lozenges, most often sold under the brand name Cold-Eeze.  In doing the research, however, I found that Dr. Steven Salzberg has already done at least three excellent reviews within the past year, and he tells us what the evidence has to say.

The first article was published back in March of 2012 here.  Apparently there is some evidence that zinc can actually reduce the length of the cold--by a whole one day.  If I'm having general ickyness for seven days or six days--it's probably not enough to make me spend the money on zinc losenges, especially since the reduction in symptoms is usually so gradual.  And then there is that possibility of losing the sense of smell, permanently that I didn't like either.  Why take that risk if it isn't even going to help my symptoms?  It looks like Dr. Salzberg came to the same conclusion as well.

Two months later, Dr. Salzberg commented on this again here.  I liked that he pointed out two major red flags that one needs to look for when evaluating studies.  One, the studies that came out in favor of the zinc lozenges were all funded by the industry--so the potential for confirmation bias was quite high.  Two, it looks like they were using those notoriously unreliable self reporting questionnaires again; one of the reasons why the decrease in cold symptoms was different for children as oppossed to adults might be that adults might be more likely to tell the researchers what they want to hear.  Once again, I wouldn't want to spend my money on something that doesn't really reduce my symptoms based on what appears to be a sophisticated advertising campaign.

And my favorite article from Dr. Salzberg was posted in July of this year.   He once again points out that most of the studies reviewed were funded by the industry, demonstrates that we need to look at more recent studies that invalidate the claims of earlier studies, discusses the value of going back to the original studies and figuring out whether they were published in peer reviewed journals, and also discusses the logical fallacy of special pleading.  This happens to be one of the most amusing logical fallacies to me for some reason, it essentially says zinc losenges will not work for me because I am a skeptic (in other words, I don't believe in zinc so it won't work).

Take home message--unless you feel like spending money, if you have a cold you can do other things like drink hot tea and eat chicken soup to ease the pain, but zinc lozenges most likely won't help you.

Tuesday, October 9, 2012

Vitamin C Bombing

It's that time of year again--the start of cold and flu season.  If you work in the health care industry, or spend a lot of time reading health related information, you know that it's the time of year to be encouraged to wash your handsget vaccinated for flu prevention, and try to stay home from work if you are sick to avoid infecting your colleagues.  Of course you are probably also going to get overloaded with all kinds of information about how to "cure" or "avoid" colds and flu with all type of "natural" or "alternative" methods.  One that I still see creeping up this time of year is the use of vitamin C in various forms to help fight colds and reduce symptom time.  Is there any evidence?  Let's find out.

Fortunately for us Skeptics, there happens to be a large body of research indicating that large doses of vitamin C do not decrease the length of colds or prevent them once symptoms have started.  One such large scale review is available for free here: Cochrane review on vitamin C.  So, number one, no evidence that this helps.

If that is not quite good enough for our non-skeptical friends, keep in mind that your body is saturated with vitamin C after 500 mg, so anything that you take in beyond that is lost through the urine.  Keep in mind that a lot of the vitamin C products being marketed to us, like Emergen-C and Airborne, are bombing us with 1000 mg of vitamin C per serving.  You apparently pay about 1 cent per milligram of vitamin C if you buy any of those products though, so that adds up to some pretty expensive urine if you purchase it.  (You will pay less money if you buy generic vitamin C capsules, but I would rather not pee out any of my hard earned dollars quite frankly).

Are there any other problems besides expensive urine?  Possibly.  People who are already at risk for kidney stones might become more so during episodes of vitamin C bombing.  There was also a study done back in 1938 that showed that the equivalent of several POUNDS of vitamin C could kill an average person, but that study was also done in rats so I wouldn't really want to test it (Link).

Are there some people who might benefit from vitamin C supplementation?  Yes, but not necessarily for colds.  There is a disease called scurvy, which is normally associated with a sea-commerce past in which sailors that had to spend months at sea without access to fruits and vegetables.   In modern times, people can still get scurvy if they have a condition, like subtance abuse, that causes them to neglect their diet; if they are a frail elderly person or young child whose caregiver has neglected to provide them with adequate fruits and vegetables, or if they are on a prolonged no-carb diet.  Since you only need about 20-40 mg per day to prevent scurvy, and even eating one potato a day will give you about 20 mg (other fruits and vegetables will give you more), we haven't seen an epidemic of scurvy lately. 

Now, if you read the Cochrane review above (you did, didn't you?) you will note that for marathon runners and people who live in very cold climates vitamin C bombing might reduce their risk of colds.  I know that's not me, and it's probably not you either.   Your 30 min jog three times per week does not count.

Take home message--don't spend your hard earned money on vitamin C supplementation for cold prevention or to lessen symptoms.

Thursday, October 4, 2012

Obligatory Breast Cancer Post

It's October, so you know what that means—Breast Cancer Awareness month.  It's usually time for me to get grumpy because of all of the "pink-washing" that goes on, so I'm just going to post a link to this website and be done with it: Think Before You Pink
There was also an excellent blog post written over at about a month ago by Dr. David Gorski, who is a surgeon specializing in breast cancer.  He talks about the dangers of forgoing conventional treatments and instead using alternative medicine, and also talks a little bit about how some people prey on the fears that women (and men) have about cancer.   Read it here: Link
Speaking of preying on people's fears, during this month you are also likely to hear a lot about diets that prevent breast cancer and even diets that "cure" breast cancer.  Is there any evidence for any of these?  Let's find out!
One of the more well known diets that is out there claiming a "cure" for breast cancer is the "Alkaline Diet,"  and it was promoted/discussed on The Oprah Winfrey Show.  This diet and it's perpetrators have already been excoriated over at The Skeptic's Dictionary here, but I feel like these words from Gabe Mirkin, M.D. are worth repeating:
"Anyone who tells you that certain foods or supplements make your stomach or blood acidic does not understand nutrition. You should not believe that it matters whether foods are acidic or alkaline, because no foods change the acidity of anything in your body except your urine. Your stomach is so acidic that no food can change its acidity. Citrus fruits, vinegar, and vitamins such as ascorbic acid or folic acid do not change the acidity of your stomach or your bloodstream. An entire bottle of calcium pills or antacids would not change the acidity of your stomach for more than a few minutes. All foods that leave your stomach are acidic. Then they enter your intestines where secretions from your pancreas neutralize the stomach acids. So no matter what you eat, the food in the stomach is acidic and the food in the intestines is alkaline. You cannot change the acidity of any part of your body except your urine. Your bloodstream and organs control acidity in a very narrow range. Anything that changed acidity in your body would make you very sick and could even kill you." (emphasis mine)

Keep in mind that this alkaline diet is promoted for a lot of other ailments, keep in mind that the "One diet to rule them all" theory is also usually a big red flag.

What about diet for prevention of cancer? 

Honestly I would love nothing more to be able to say "eat more of this and you will never get cancer, breast or otherwise," but since I try to be the best scientist I can be (and I also have scruples), I can't tell you that.  One of the problem is that there are many people that still do not understand that correlation does not equal causation.  It also doesn't help, in my humble opinion, that you can see a headline like "Foods that Fight Cancer" pop up on the American Institute for Cancer Research's website.  Fortunately they are willing to immediately counter with "there is no one food that can prevent cancer," but it still makes me cringe because I know not everyone is going to ignore the headline.

So, apparently there is data that eating more plants is associated with a lower risk of cancer—but it's just an association based on observational studies, and you remember what I said about observational studies before—you can say "huh, that's interesting" but you can't start pointing out cures.  There is apparently data that states that having lower body is associated with a lower risk of cancer, but once again, observational studies are at play here.  Are there other reasons to eat a lot of vegetables?  Sure, the do ensure that you get micronutrients for your body to function overall correctly and since they have a low caloric density you can fill up on them to limit overeating on other things.  Are there other reasons to lose excess body fat?  Sure, improved insulin sensitivity for those who are diabetic and pre-diabetic, you can breathe easier if you have lung problems, less wear and tear on your joints, better blood pressure, etc.  But you can't point to a particular food, or even a particular diet plan, and say "this will keep me from getting cancer."

More recently there was another diet/breast cancer association reported on—apparently there was a higher risk of breast cancer in those with higher cadmium rich food intake (Link).  Unfortunately, once again we are using the notorious unreliable food questionnaire (remember that?) and even the authors of the study cautioned that we really don't know what the association between cadmium consumption and breast cancer is—and they also pointed out that high levels in a person's body might come from other sources like smoking, etc.  And they were also quick to point out that cadmium might be found in—you guessed it—plant foods.   (I can hear it now, "What am I supposed to do, quit eating?"  No, you need to stop making judgments about your food without having evidence to back it up.  There isn't enough evidence to tell you to quit vegetables, etc.)

Take home message—it's not going to hurt you to include more vegetables in your diet for a variety of reasons.  We don't know enough about cadmium rich foods to start making recommendations.  Will eating a certain way keep "the big C" away?  Maybe, maybe not. 

Wednesday, October 3, 2012

Tips for Trips

Since I am still jet lagged from my trip traveling is on my mind.  Of course a lot of people also use traveling as an excuse to eat things that they normally don't, and sometimes they regret it later—they might have gained weight, had GI distress, or had an exacerbation of some type of chronic condition that they have (out of control blood sugars, etc).  There's no reason why you can't have a little treat while traveling, but you want to make sure you don't regret it later.  Here are some tips for traveling and still, for the most part, staying on your eating plan (some of these tips were discovered the hard way, you can thank me for my sacrifice later).
1) When you arrange for your hotels, go ahead a do an internet search for restaurants in the surrounding area.  That way you won't have to try to make your decisions on where to eat when you are tired, cranky, and so hungry you want to eat everything in sight.
2) When you arrange for your hotels, find out what kind of meal facilities they have on site.  If they serve breakfast, find out what they have.  If they have a restaurant, see if the menu is available on line or if the hotel can send you copy of that day's menu to see what kind of options they have.
3) Bring your own snacks, preferably non-perishable if you are not sure of your refrigeration situation at the hotel or you are going to be flying.  Beef jerky (gluten free and grass fed for me) is one of the original portable foods; nuts, little cans or pouches of tuna, fruit, etc also travel well.  If you are on a road trip, bring a little cooler or lunch bag that you can fill w/ice at each hotel stop or gas stop. 
4) Try to avoid going inside the gas stations with all their available goodies if possible.  Pay at the pump, only go in to use the restroom and walk out immediately after,  etc.
5) If you are attacked by some goodies while you are at the gas station, try to at least get the small bag of Skittles (or whatever your favorite treat is) instead of the large one.  Don't start eating them until you have driven away to avoid the temptation to go back for other things.
6) Look for restaurants where you can get breakfast all day like Denny's, IHOP, etc.   are you can always default to an omelets (protein/veggies) when it seems like deep fried items are the only thing available elsewhere, and most of these places are open late or at "odd" hours as well.
7) Many large chain grocery/department stores are located close to highways, make use of them for a quick meal or to pick up some snacks.  As someone who makes home visits in remote areas, I know that there will always be a Wal-mart available even in the smaller towns.
8) If you are going to eat fast food, choose the smallest size burger, etc that they have.  Don't be afraid to modify and ask for things without the bun, etc.  Once again, you can look up the ingredients ahead of time on the internet, or use your smart phone.  I actually have an iPhone app that gives a short list of gluten free items at many chain/fast food restaurants.
9) Bring water bottles with you and fill them up at the beginning of the day so you can keep track of your fluid intake.  Getting slightly dehydrated can make you feel more tired and cranky as well.
10) Think about what's going to happen after you come home—stock your freezer with burger patties (turkey, grass-fed beef, black bean, or whatever), nitrite free sausage, casseroles, frozen vegetables, etc before you leave on your trip.  That way you will have something that you can prepare quickly when you get home without having to make an extra trip to the grocery store when you are tired (or you get back too late to visit the store).
Take home message—plan ahead, plan ahead, plan ahead.

Tuesday, October 2, 2012

For fun: Some of the stranger questions I've received

Last week while traveling I was regaling Boyfriend of SkepticRD with some of the stranger conversations/questions I’ve had over fifteen years.  I thought I would ease back into blogging this week by sharing. Of course I wish I had written them all down, because I would have had way more than ten, but here is a sample, with explanations, of course.
1)      Mr. Tight: Which is better, white or whole wheat bread?
Me: Whole wheat bread does have more fiber….
Mr. Tight: Does toasting it make a difference?
Seriously, do I need to explain this one?

2)      Mrs. Sweet: If I add water to my soda, doesn’t it lower the sugar content?
At this point I had to explain some basic laws of chemistry.  If you pour twelve ounces of soda into a glass, there is about 32 grams of sugar in the glass.  If you add water to it, and still drink the full can of soda out of the glass, you still drank 32 grams of sugar.

3)      Mr. Deafasapost:  I heard “a doctor” say that diet soda had just as much sugar as regular!
At this point I bring out the label from the soda bottle and ask him exactly where the sugar is hiding.  Then we have a conversation about how what you hear and what you remember might be different things and it’s always good to take notes.

4)      Mr. Sweet: If my sugar is really high, can I drink a lot of water to bring it down?
I basically said something along the lines of “I wish it was that easy.”  What I think he might have heard, however, is that if your blood glucose levels are very high you are more at risk for dehydration, which is true, so you do need to ensure adequate fluid intake when your blood sugars are high.  Too bad that glass of water won’t “flush” that piece of cake from your system.

5)      Mr. Inkspot:  I want to get a tattoo, but I’m diabetic, do you think that would be ok?
I included this story because it was one of the more random questions that I got on a slow clinic afternoon, but it was actually a very good question.  If you have diabetes that is poorly controlled you are at very high risk for getting a very bad infection (and possibly losing a limb or your life) if you get a tattoo, piercing, or even a bikini wax.  Once your diabetes is under control and has been for at least six months to a year you could, in the words of the endocrinologist I used to work with “tattoo your whole body if you want” but you should also take extra special care of your blood sugars and your skin while going through the healing process.

6)      Mr. Eatsalot: Can’t I eat whatever I want as long as take my insulin?
It depends.  For most of my patients, who have Type 2 diabetes, the answer is no.  These type of people are usually on a set dose of insulin every day, and if they eat too much carbohydrate one day and very little the next, their blood sugars are going to be all over the place.  And if they keep eating a lot they are going to have to take more insulin to control their blood sugars, and having to take more insulin can sometimes increase the appetite, leading to them eating more, which increases the weight gain, which makes them more resistant to the insulin, which means they have to take more insulin……so yes you could, but your health might suffer in other ways.  Now I do know and have some patients who have Type 1 diabetes and have done the work of intensively testing their blood sugars so that they can adjust their insulin based on how much carbohydrate they’re eating and still keep their blood sugars under control (quite often they use an insulin pump also).  Over-consuming anything however, can still lead to weight gain and all the problems that can go with it—poor circulation, cardiovascular disease, etc.

7)      Mr.  Politico: “Are you a conservative or a liberal dietitian?”
I was about to tell him that I don’t discuss politics at work, because I only have a limited time to spend with people, and then I realized he was wondering if I was open to new things.   We actually had a good discussion about re-evaluating one’s practice based on new evidence and not being so open minded that your brains fall out (per Michael Shermer). 
8)     Mrs. Knowitall:  I’m allergic to wheat bread.
Me: So, what do you eat instead of bread?
Mrs. Knowitall:  Oh, I still eat bread, but I just eat the white bread, not the wheat.
And what’s really sad is that I have had that conversation more than once.

9)   Mrs. Aquarius:  “We don’t eat anything with chemicals in it.”
This was the wife and chief meal preparer for one of my patients.  She spent a lot of time talking about how they wanted to do everything “natural,” but I noticed that they had no trouble asking for a prescription for Viagra.  I have also had this conversation with plenty of people who smoke cigarettes that they didn’t exactly roll themselves, so chances are they are willingly taking in some more "chemicals" than what they are willing to admit.

10)   Doctor I.M. Clueless: We think this patient is lactose intolerant, do you have a quick and dirty test for that?
What I wanted to say was “Have him drink a quart of skim milk, that will be both quick and dirty.”  But I was nice and said to have the guy remove all dairy products for two weeks and see if the symptoms resolved.

 Take home message--most of us are going to be nice no matter how odd the question.  Don't be afraid to ask and learn something.