Herbs for Organs--Part One

If you thought this was going to be a post about what kind of herbs go with liver or kidneys, you are out of luck. (You can also cue in the Hannibal Lecter jokes).  No, a friend pointed me to this pic and asked me to debunk it:

Included was the caption:
 Herbs For Organs - Our bodies have the ability to naturally flush out toxins if we provide the right environment for our organs. Include these herbs in your diet to help your bodies natural detoxification process!

I have talked about detoxification before, but I will summarize again.  The bodys detoxification system, like the immune system, is rather like a tire.  It can be low, it can be at normal capacity, or you can try to overfill it.  It can be low because of illness or a chronic problem that has gone untreated (bad), it can be working normally, or you can try to enhance it and have it blow up in your face (also bad).  If your kidneys and liver (the main cleansing organs that people think about) are failing, you can attempt to remove the offending problem, but you cant enhance the function.  For example, if a person with uncontrolled diabetes gets told that their kidneys are not clearing wastes like they should (via blood and urine tests), and they wise up and get their blood sugars under control, they cant slow down and even halt their progression toward dialysis, but they wont actually improve their kidney function.  What you can do to keep all your organs working normally is avoid binge drinking and excessive alcohol intake(liver  ), lose weight if you are overweight(kidney and liver), control your blood pressure (kidney), control your blood glucose (kidney), dont engage in drug abuse/share needles (liver and kidney), be careful of what and how much medication you are taking (liver and kidney), and try not to get poisoned or hit by a bus (well, thats bad for all of you I think).

As far as the different herb listed here, is there any evidence for the use of these or any harm?


1) Ginkgo Biloba (note the correct spelling)--the larger the studies get, the less evidence they find. (Link).  This herb also increases your risk of bruising and bleeding.

2) Ginseng--This herb has been the butt of so many jokes I find it hard to believe that people think this actually does anything, but once again, no memory helpers here (Link).  Some people also get insomnia from this herb, and poor sleep will not likely help your memory.  I am also amused that ginseng is thought to enhance male sexual function because the root looks like a male organ; interesting that carrots, cucumbers, bananas, etc do not carry the same claim.

3) Cocoa--there is some evidence pointing to the cardiovascular benefits of cocoa, but it is mostly observational (Link).  Could it hurt?  Yeah, if you are eating products that are more sugar than cocoa and gain a bunch of weight (you know who you are!).  You can eat the 70% or higher chocolate, try not to eat the whole bar at once (even if it is fair trade), or use the internet to find a multitude of low sugar ways to work it in (including savory chili recipes).

4) Garlic--kind of in the same boat as cocoa here (Link).  Some folks do get side effects like nausea, vomiting, diarrhea, and general stinkyness when they take the powders, and you need to make sure that it does not interact with any other medication you might be taking.  I was also fascinated to find out that the use of garlic paste for fungal skin infections could result in a burn.

5) Mullein--sorry asthma sufferers, no good evidence here.  Might also cause bleeding (Link)

6) Yarrow--not sure why the arrow appears to be pointing to the lungs, having it point to the stomach or uterus would have made more sense.  Too bad it will not help with those cramps though. (Link)

7) Milk thistle--has some promise for reducing death in people who have cirrhosis, but we need better studies.  Overall safe unless you are allergic to related plants like daisies (Link).

8) Dandelion--see above as far as not being able to help your liver perform better.  Tastes really good in a salad, though some people might not like the bitter taste.

9) Chamomile--not enough evidence say it helps tummy trouble, but if you want something non-caffeinated, go ahead.

10) Licorice--this one might help GERD, but only when combined with certain other herbs ( Link).  Can cause severly elevated blood pressure when used chronically though.

11) Ginger--not sure why this is pointing at the kidneys, probably meant to point to the stomach.  And we did this before.

12) Bilberry--once more, I think we were pointing to the wrong organ.  Maybe they were trying to point to the pancreas as you often see this herb and diabetes mentioned together.  Too bad there is no good evidence for that either. (Link)

Stay tuned to cover the other side!

This post might give you Heartburn.

Where I work we have a lot of patients taking medicines for Gastroesophageal Reflux Disease (GERD), more coloquially known as "heartburn."  The usual prescription for said problem is a medicine called a Proton Pump Inhibitor (PPI), usually sold under the names which include esomeprazole (Nexium), lansoprazole (Prevacid), and omeprazole (Prilosec).   These medications are meant to be given in the short term only (like maybe 4-8 weeks), but a lot of our patients have been on a PPI of some type or another for years.  Unfortunately, these medications can have long term side effects as listed here, and since I work with a mostly elderly population healthy bones and healthy B12 levels are a major concern.  Also unfortunately (and understandably) there are plenty of people who don't want to stop taking the medication because they don't want to resume the pain and nausea, etc of their pre-medication days.  There are, however, some people who wish to attempt to treat this by lifestyle changes, which is where my part, and the fun part, begins, as people will usually find more than one way of treating it, not all of it evidence based.

Let's start with what we know, and that is that GERD is caused by intra-adominal pressure--bloating of the stomach that puts pressure on the lower esophageal sphincter (LES) and/or lifestyle habits that weaken the LES.  Having extra abdominal fat (aka being obese) can cause this pressure, and lifestyle habits like smoking can cause your LES to be weak.  Other common triggers seem to be alcohol, spicy foods, deep fried foods, peppermint, garlic, and onions, caffeine beverages, and coffee of all types.  (My friends who are pregnant have also complained of GERD)  I always remind people that what triggers each person is going to be different, and I have encouraged people to keep a diary of what seems to exacerbate their symptoms--some people have no trouble with raw tomatoes but they have trouble with tomato sauce, for example.  For people with active symptoms they also need to leave a gap of anywhere from 1-3 hours between eating and going to sleep and need to sleep with the head of the bed elevated.  I also remind them that even though giving up coffee, etc might be tough for some of us, you don't need it to survive.

Now we come to the more murkier part of the lake.  One of the things that people have been told to do when they have GERD is to severely lower their fat intake--as in all fat.  Fat does have a tendency to slow down the emptying of the stomach, which could cause more pressure, so I can see where this recommendation comes from.  Unfortunately, however, over the years I have seen food lists that tell people to completely stay away from red meat and encourages the use of processed foods like "fat free" cheeses, etc.   That's enough to make me want to ignore dietary advice and just take medicine right there.  I think a more balanced approach would be to eliminate deep fried foods and other foods high in trans fats and all the unnecessary vegetables oils that people add to their food.  Stick with leaner cuts of beef and pork at first, and use olive oil, butter, and nitrite-free bacon sparingly until you figure out what your tolerance is.

One other problem piece of advice is "eat six smaller meals per day."  I think maybe what those who give this advice really mean to say is "try eating less at a meal" or "quit pigging out until you'rencomfortable."  If you are someone that that gastric bypass surgery or you are trying to gain weight, you might have to spread your nutrition over six meals a day, but if you are overweight or trying to maintain your weight, six meals per day might result in weight gain or inability to lose weight.  I have also had some people that experienced nausea if they didn't eat every two hours--in that case you better keep a closer eye than usual on your calorie intake and/or consider taking a PPI temporarily so that you don't gain fifty pounds.

And then there's the people who find relief by restricting their carbohydrate intake as was done in this study (Link), and I have heard some anecdotal reports of this happening as well.  Keep in mind that the people in this study did lose a significant amount of weight in a two week period of time, likely reducing their abdominal pressure, as the authors pointed out.  Since this was a small study and only done in obese women, the authors can't state that everyone who reduces their carbohydrate intake will have a relief of symptoms (and it sounded like the weight loss just benefitted them period).    There are some other theories out there though, and since I did experience one of these myself, permit me to get all anecdotal on you for a moment.  Remember this post where I talked about the elimination diet I did to improve my IBS symptoms?  Remember what those foods that contain FODMOPS do (like wheat, garlic, onions, etc)?  That's right, they can cause gas, bloating, and our nemesis the intra-abdominal pressure again.  I stopped eating the things that were causing me to bloat and compress my stomach and I got stop dealing with daily nausea/GERD symptoms. (Some of the other anecdotes I saw involved people specifically pointing to avoiding gluten as a "cure" for their problems--if the gluten was causing flatulence and bloating, as is the case with celiac/gluten intolerance, then it probably did relieve the pressure and symptoms.)

So, what do you do if you would like to avoid medication for GERD?
1) If you are overweight/obese and most of that extra body fat appears to be in your abdomen, losing weight will often improve symptoms.  If you have been overeating on carbohydrates (you probably need to cut way back to lose weight).
2) Eat just enought of the "good fats" at each meal to help things taste good, you might have to experiment with how much olive oil, etc you can put on your salad.
3) Keep a diary for at least two weeks of foods eaten and symptoms.
4) Consider going on a low FODMOPS diet (see link above), especially if you also have trouble with belching, feeling bloated, or flatulence.
5) Quit smoking if you smoke.
6) Avoid caffeine, alcohol, and spicy foods for at least two weeks, and consider adding small amounts back in to see if you tolerate it (I used to not be able to have coffee, but since I eliminated the other problem foods I can drink it now).

Would you like your whale skin raw or pickled?

So last week I wrote a blog post about what can happen when someone takes a diet to an extreme.    Since I have the priviledge of hanging out with smart people who love obscure bits of knowledge as much as I do, however, it means that I also get questions that sound something like, "Oh yeah?  Well, what about those Inuit, who subsist on caribou and no vegetables, eh?" 

First of all, let me point you all to an an excellent article published by Discover Magazine called the Inuit Paradox.  And now, let me give my own answers.

1) You are interested in a way of eating other than your own.  Good for you, prepare to have your eyes opened.

2) Unless you have known Inuit ancestry, this probably doesn't apply to you.  Meaning that you can't look at a group of people that has certain genetic adaptations, like a larger liver to handle a higher protein diet, and extrapolate that to a Caucasian woman from Pennsylvania like yours truly.  I am not saying we should completely dismiss the nutritional findings here, but not all of it will apply.

3) You don't eat like an Inuit.  Yeah, yeah, I know some of you are careful to only eat grass fed beef, animals that you have killed yourself, and you might even eat liver on a regular basis.  But are you eating raw muktuk?  What about the raw livers of Beluga?  Or the stomach contents of caribou who are kind enough to pre-digest those tough artic plants for us?  No?  Well, even if you find that appealing, because of restrictions on importing marine life you will probably have trouble finding that type of food if you live outside of Alaska and Canada.  In other words, you are probably not getting those animal foods that actually appear to have vitamin C or are (not) processed in way that they retain vitamin C. 

4) You don't live like an Inuit.  I know some people are trying to engage in more exercise by lifting heavy things, but chances are you don't have the same stress levels, social interaction, or food access.   People living a "traditional" lifestyle would not have had to deal with the constant lure of food that is tasty but not nutritious (of course the internet is full of people that claim they are above temptation, but not all of us are there yet.)  The Inuit also engage in food sharing--those who can hunt and gather and have success at it take what they need for their families, and then the rest gets shared with elders who can no longer hunt or families that didn't have as much luck during their hunting/gathering.  I would say that would definitely mean less reliance on poor quality food because of financial insecurity, wouldn't you.

Is there anything that we can learn from this lifestyle?

1) Sometimes we actually have to create our own version of scarcity to keep our weight under control and try to avoid the problems associated with obesity.  Fill your fridge and freezer with healthy sources of protein, good fats, plenty of vegetables, fresh/frozen fruit, and don't buy the high calorie/low nutrient things.   "Store up for the winter" buy using your modern appliances like slow cookers, etc to make food that can be frozen and reheated for quick meals, and stock up on jerky and other non-perishables snacks.

2) Fat by itself is not the "demon" that media reports make it out to be, but you still have to be careful what kind of fat you are eating.  The fat that comes from grass fed beef, foraging pigs (nitrite free bacon!), or free ranging chickens (or seals, if you have access to that) is usually going to be higher in omega-3 fats and monounsaturated fats that feed-lot beef, etc.  Now, I know that not everybody has access to or is willing to pay the price for that (your body, your finances, your choice), so you can still get your "good fats" by doing lean cuts of conventional raised protein and filling in with olive oil, coconut oil, etc. 

3) People from different regions have adapted differently, and our evolution didn't stop 10,000 years ago.  So if you tolerate "non-Inuit" foods like dairy, grains, and legumes, try to stick with with the most unprocessed versions possible so you can actually get some nutrition out of it.  (So your cheese should not be flaming orange, your grains not powdery white, etc).

4) There are different ways to get the nutrients we need.  Try to aim for as much of a variety of protein sources, good fats, fruits, and vegetables as you can, and be willing to try some things that are not part of your culture.   There may be some things you love, and others you don't.

4) Exercise portion control.  Put just enough on your plate to satisfy you, and either share the leftovers with someone else or store it up for later.  Be creative with your leftovers--even if making fermented seal meal doesn't appeal to you, you could probably cook up a whole chicken and find ways to use the leftovers in other meals.

Take home message--Studying the eating habits of different cultures can teach us a lot.  We have to be careful, however, of how we extrapolate that information to other populations.

Crazy Cat Lady, RD

This morning I was both fascinated and amused to see this story pop up in my news feed: Supplementation Necessary With Raw Meat Diet For Cats (or Tigers).  I was interested because a) I care about the health of my two orange tabbies so I want to feed them right, b) I have long entertained fantasies about running a weight loss clinic for overindulged pets, c) I have long been fascinated by the lengths that people will go to to take care of their pets, and d) I thought it might have some applications to humans.

So, yes, I do find it fascinating that people buy frozen rabbit carcases and grind them up in the kitchen and then freeze them in portions for later, as detailed on this website managed by a veterinarian.  It's not something I choose to do, but I have learned a lot about what kind of higher-quality food to look for (and seen more pictures of cat poop than I care too).   I also find it fascinating that even though she recommends feeding a cat as close to "nature" as possible, she recognizes that cats can benefit from more than just having a couple chicken thighs thrown at them (as apparently confirmed by the study).  In other words, even though the cats would survive on those chicken thighs, they likely wouldn't thrive.  And even though my cats often look longingly out the window, wishing they could catch the geckos and squirrels that torment them from the porch, I think they prefer their temperature controlled environment with a constant source of food.  (Yes, even skeptics like to anthropomorphize their animals.  I think you only need to worry about me when I start trying to ulilize the "pet psychic" that often appears at the fund raisers for the local animal shelters).

Now, how does this apply to people?  Think about certain people you know who also want to keep their diets as close to "nature" as possible, which for some people means staying with mostly meats (with fat, hopefully) and whatever vegetables they can scrounge up.  They have definite advantages in keeping excess calories away, and if they are pre-diabetic or have type 2 diabetes it will definitely keep their insulin levels from being elevated and blood glucose levels from going out of control.  Some people become so worried, however, about keeping their insulin levels down that they resort to an ultra-primitive plan (think sitting in a cave munching on jerky and maybe a little dried fruit in the middle of winter--also called a zero carb diet). Could this ultra-primitive diet cause some ultra-primitive problems?  The answer is yes, and one of those problems that is resurfacing is a disease that many people thought went away with the dissolution of maritime commerce--scurvy.

Just like cats can't synthesize taurine in their bodies and must get it from food, humans can't synthesize vitamin C and must get it from food sources.  Additionally, we do actually need to produce a certain amount of insulin to absorb vitamin C for our bodies to recycle it.  So if someone did try to do a zero carb diet for a significant length of time, even if they were eating some red peppers or other vegetables high in vitamin C, they won't be able to use it.  So, you will want to make sure that you eat enough carbohydrate to produce the right amount of insulin.  I know for me that won't be a problem!  Does that mean that you start eating platefuls of pasta, and cartloads of candy, and oodles of orange juice?   Sorry, but no.  You can, however, add back small portions of fruit (like a cup of berries, not the whole flat!) a couple times per day, add a little sweet potato here and there, or a little bit of unprocessed rice and/or quinoa; in other words, add back high nutrition carbohydrates in small portions and stay away from the processed stuff.  (And if you have diabetes, you might need to test more often to make sure your portions aren't too big!)

Take home message--going to extremes with any plan will probably hurt you in some way.  You might need to keep your carbohydrates low, but make sure you eat enough of the nutritious kind. 
Oh, and make sure your cats have a balanced diet too.

A fight that isn't.

Many of us do long for a simple world, one where we can find the perfect way of eating that prevents and cures all ills, and for some of us, when we think we have found it, it turns into the proverbial sacred cow that no-one better say anything bad about it.  There are also those of us that recognize that it is one thing to have a sacred cow, and another thing to exercise caution, but apparently that doesn't always make for the best of stories, so we have to make up fights.  And that's what I noticed when this article popped up in my feed.

The headline and the final paragraph basically scream "Scientists are fighting about whether or not calories matter!" but if you will read the actual article you will find that's not true.  Dr. Carmody and the others part of that symposium are not telling people that they should ignore food labels and calories--they are merely saying that food processing has changed in the past hundred years that Atwater came up with the conversion so we probably need to change the way we do things to provide scientifically accurate information.  So the "fight" and partisanship that suppossedly exists between Dr. Carmody and Dr. Nestle doesn't exist, period.

I have previously blogged about how we can actually look at calories while examining the quality of food and hope that I made a good case for finding a balanced approach to eating healthy while loosing wt.  (I should probably add that I do get a little cranky, however, when people are quoted as saying "just eat less" and there's no discussion about food quality.  Did I tell the story about my patient who carefully watched his calories during the day so he could have a six-pack of beer nightly?)  I also find this news from Dr. Carmody's group exciting for a couple reasons.  One, I just get excited about the potential for newer and more accurate ways to measure things (because I am a nerd).  Two, I hope that those who have been obsessing over every single last calorie might be able to loosen up a bit and have a little bit more room in their life to look at quality of food.  Three, I hope that those who have thrown out looking at calories will be tempted to take a second look at how much they are eating (I'm looking at you, low carb people who are pigging out on your almond/coconut flour brownies!)

So is there any information that we can take from this.  Keep eating food that is unprocessed and without a lot of add ons as it is more likely to fill you up faster and longer to keep you from overeating.  And pay attention to how much.

Take home message--look at calories and quality.  If you are going to rubberneck a fight, make sure one actually exists.

The Vitamin that Doesn't Exist

I'll admit it, I'm a rubbernecker, especially when it comes to viewing the scary information that people put on their blogs.  I went down a really frightening "I've got to stop reading this but I can't" path today on a blog that was not only filled with a lot of nutrition woo but also commentaries on home-births and why women should stay with their abusive husbands.  I'm not even going to link to it so that I don't give her blog more traffic than necessary, but I do want to talk about how she mentioned that she will never have cancer because she and her husband are eating apricot pits on a daily basis.  Why apricot pits?  Because they contain something called "Vitamin B17" or Laetrile.

I will have to humbly admit that this one was new to me.  Fortunately, our friends at Quackwatch have already written about this topic fairly recently.  I give you the article that details the wild and crazy history Laetrile/Amygdalin and the people who have advocated for it.  And let me highlight this quote from the post:

"The results of the trial were clear-cut. Not one patient was cured or even stabilized. The median survival rate was 4.8 months from the start of therapy, and in those still alive after seven months, tumor size had increased. This was the expected result for patients receiving no treatment at all. In addition, several patients experienced symptoms of cyanide toxicity or had blood levels of cyanide approaching the lethal range. An accompanying editorial concluded:

Laetrile has had its day in court. The evidence, beyond reasonable doubt, is that it doesn't benefit patients with advanced cancer, and there is no reason to believe that it would be any more effective in the earlier stages of the disease . . . The time has come to close the books." (See the linked article for the citations)

Not only were these people not cured of cancer--several of them were actually poisoned.  Once again, I find it fascinating that people will call medicine "poison" and then willingly poison their own bodies with something else.  (Fortunately three apricot pips per day shouldn't cause an adult to be poisoned, but I do worry about children consuming them and people who do think "more is better."

I also found this post at Skeptic Dictionary about one of the proponents of laetrile, Phillip Day, particularly how he claims that all of us in the medical profession are deliberately with-holding "dietary cures" to make money.  Let me highlight these quotes by the author of the post:
"But it is a long way from these facts to the notion that food alone can prevent and treat all illnesses or that food or the lack of a specific food alone is the cause of all illnesses."  In other words, there is no one vitamin (even those that actually exist) that will keep you from getting cancer, or that will actually treat it once you have it.  I will admit to wishing it was that simple myself on some occaisions, but as Ben Goldacre says over at Bad Science, "I think you'll find it's a bit more complicated than that."

Take home message--you probably aren't going to get poisoned from three apricot pits per day, but there's no good reason to include them either.

 

Herbs that Heal What?

The other day a friend was complaining about being bored with Facebook.  I haven't reached that point yet, since it still provides me with plenty of fodder for a blog, like this:

In the interest of time and space, I will only cover what is mentioned on the graphic, even though I have heard of other attributes of these herbs.

1) Dill and killing "harmful intestinal bacteria."  I was actually able to locate a few small studies that indicated the essential oils of several herbs were actually able to break down the cell  membranes of salmonella, etc.  (Link) The caveats, however, are a) that these oils were applied to bacteria in a petri dish, not in a human body, b) the oils were applied in a particular concentration which likely including more than what I would use to season my salmon, c) when this particular herb is taken in capsule/tea form (aka. at therapeutic concentrations) it might actually interfere with anti-biotics (Link).  Moral of the story--if you are taking antibiotics do not use dill in high concentrations (using it as a seasoning should still be ok).  If  you suspect you do have e. coli or salmonella see a health care provider ASAP, and until we know more about the appropriate concentrations of essential oils to break down cell membranes, cleaning countertops and cutting boards with a bleach solution is your best bet.

2) Parsley as a diuretic?  There are some limited studies that parsley does actually have diuretic properties. (Link).  The problem, however, is that if your heart function and/or kidney function has deteriorated to the point that you are actually retaining water, you have more problems that just feeling a little bloated.  Also, listing something as a "powerful diurectic" is not a good thing--you can wind up with severe electrolyte imbalances which could actually lead to dehydration and shock.  When people with heart failure and kidney disease are prescribed diurect they need to have regular lab work to make sure that they are not having imbalances, and chances are people self-medicating with "herbal" diuretics are not getting the same lab work done.  Moral of the story--if you are having trouble with mild fluid retention and you know it's because you had a processed food binge (i.e. your sodium and processed carb intake went way up), then go back to eating and drinking in your usual healthy way and it will resolve on it's own.  If you have fluid retention and are experiencing shortness of breath, call your physician at once.  If you have known heart failure and your weight increases by more than three pounds in a day or two, call your doctor at once.

3) Cayenne fighting congestion?  There is some evidence that cayenne might fight the type of inflammation that causes arthritic and nerve pain, particularly if you are a rat living in a lab (Link).  But this isn't the same type of inflammation that you have when your sinuses are clogged up from a cold or allergies.  So why does our "nose run" whenever we eat hot food (i.e. Why is there so much anecdotal evidence for "hot/spicy foods" clearing congestion?).    In short, whenever you eat something hot, the active ingredient in cayenne (capsaicin) binds to the pain receptors in the nose, mouth, and skin.  Your body wants to get rid of the irritating agent, so the mucus glands in your nose start working overtime to clear out the offending substance. (More details here from the Food Explainer!).  Moral of the story--if you are congested eating something spiced with cayenne can provide you with temporary relief from congestion, but not for the reasons listed here.

4) Basil and depression?  In this case, one tiny little study was done in India to see if controlled portions of basil extract would help depression, but there was no "this will help improve your mood in three days." (Link)  Once again, I want to point out that if this did work, increased levels of dopamine are not necessarily a good thing--which is why people who take Wellbutrin for depression and Levodopa for Parkinson's need to be carefully monitored to make sure they are not having hallucinations, etc.  I know there are plenty of people who don't want to take medicines because they are worried about side effects or lining the pockets of "Big Pharma," but I don't think they want the side effects of herbal medicines or to line the pockets of charlatans either.

5) Cilantro as a way of removing heavy metals?  If you actually have mercury poisoining, you will need more than cilantro to remove it from your blood.  The only way to deal with mercury is to limit your exposure as much as you can.

6) Ginger for nausea?  Saving the best for last as there has actually been a bit more research on this one, but it depends on what it causing the nausea and what you are comparing it to.  If you have motion sickness, nausea from chemotherapy, and/or nausea after an operation, the ginger works better than a placebo.  If you have "morning sickness," however, ginger doesn't seem to be as effective.  And "better than a placebo" is not "better than motion sickness drugs," (Link)

Take home message--these herbs are tasty (in my opinion) but the only claim that has a little merit is the ginger for nausea.  If if the others did work, you probably don't want those side effects either.

Opinion: Let's Call a Spade a Spade.

Sixteen years ago when I became a Registered Dietitian, a popular motto of those in my profession was "All Foods Can Fit."  I found out relatively quickly that a) mottos are not necessarily based in evidence, period and b) what you learned in school does not always translate to reality either.  In other words, I learned that even though TECHNICALLY people could work certain foods into their carbohydrate allowance it was better for certain people to not to eat certain foods (even when we weren't dealing with an allergy) because certain foods just caused too much of a hindrance--whether it be from a physiological standpoint (i.e. even a small amount caused elevations in blood glucose) or from a psychological standpoint (i.e. just have the oreos there causes you to think about nothing but Oreos until you eat most of the package).    Now I've noticed that sixteen years later, according to the Academy of Nutrition and Dietetics (AND), this same motto or argument is appearing in a different form.

Please permit me to go anecodotal and speak from my own experience for a minute or more.  I still think that technically they are correct; if I as an "authority figure" try to tell someone that this is "good" and that is "bad" or that they "can/can't" have something I will be seen as keeping them from making their own decisions.  (And if you have the contrarian type of personality like Boyfriend of SkepticRD, you will eat whatever you are not supposed to just to spite the offending party).    I still have a lot of patients who ask me, "can I eat that?" and my answer usually goes something like "You can eat whatever you want BUT you have to pay the consequences," or "We just talked about what carbohydrate does to your blood glucose, so what do YOU think will happen?" or "Try it and see what happens, then you decide."  So, yeah, technically I'm not calling anything bad. (Unfortunately I do have some patients who are cognitively impaired, and I do have to take a yes/no approach, but that's another story). 

But then there's the reality. Let's say you have a person with Type 2 diabetes, treated with just a small amount of medication at this point, and she really, really likes potatoes.  She tries eating just a half a cup of potatoes, because she knows that should fit into her carbohydrate allowance, and she sees that her blood glucose is 50-100 points higher after that meal.  She thinks maybe that was a fluke, and tries it again at another meal--same results.  Tries it a third time, just to be sure, same results.  So, now she has decided ON HER OWN, that potatoes are a "bad" food for her.  Now she's coming to me for advice about what else she could eat.  If I am taking the "all foods can fit approach" (and trust me, after 16 years I've seen this happen way more than I care to) I would probably give her a long speech about not being "afraid" of potatoes, the benefits of potatoes, portion size, etc.  If I took a reality-based approach, I would say "good for you for figuring out what your body can and can't handle and here are some other foods you could try substuting for your carb allowance and see how they work" or "good for you, here's a recipe for cauliflower mashed potatoes that's really good" etc.   Do you see the difference?   The first one assumes me as an authority figure who completely ignores the work that she's done and what impacts her individually, the second approach shows how she and I work together and come up with some alternatives.

I think the other thing that AND is worried about is that by labeling certain foods as bad, or even acknowledging that some people have declared certain foods "off limits" for themselves, is that people will wind up beating themselves up when they eat a potato (or whatever it is) and just give up on the diet in general.  I definitely agree the "I made one mistake so I'll just give up" approach is not exactly healthy, but that's where I get my psychology co-workers involved to help cultivate a healthier attittude.   I would probably still work with that person to see if there are ways that we can safely work that food into their plan on a scheduled basis, but if that person decided that it was better for them not to have any amount of a particular food, and there really was no value to it, we would work on finding substitutes.

Another concern that is also raised is that by labeling certain foods as "bad" people will stop eating entire categories of food and wind up with nutrition deficiencies.  I suppose I tend to be a little grumpy about that one since when I was a vegetarian everyone assumed I wasn't getting enough protein, and that wasn't the case, and when I went gluten free--everyone assumed I would be deficient in something, and that wasn't the case either.  It does happen, like my patients who are still afraid to eat ANY fat at all because of something they heard in the 1980's, but once again, if people are counseled on healthy alternatives (or they are motivated to do the homework themselves) there's no reason that you need to wind up with a deficiency.

One of the other things that I found didn't translate so well was that people would "just" look at the carbohydrate and/or calorie content of a food and stop right there.  For example, if you have a small apple or approximately two Oreo cookies, your carbohydrate content is roughly the same.  The apple, however, will take longer to eat (helping you not eat as much), give you soluble fiber (pre-biotic and helps you fill up faster, so you don't eat as much), and also provides a little vitamin C and potassium, etc.  The Oreos are just, well, there, not really doing anything for you.  And a regular diet of no nutritional value could wind up coming back to haunt you.  I have always cringed when I saw the cookies and the fruit in the same "carbohydrate exchange" category because for all practical purposes it looks like we as health care professionals are putting cookies in the same category as fruit, and not everyone takes the extra steps to figure out that it not the case.  So yeah, I still have to put foods into "green light" and "red light" categories just to help people along.

Take home message--if you have decided certain foods are your "off limits" list for a legitimate reason, and those foods don't have any nutritional value anyway, then you have my full support.

Conspiracy and Comparisons

Here in the United States we are confronted with a lot of choices on what to eat, and making the right choice can be difficult to say the least.  Sometimes it seems that there are "forces" fighting against us, and those roadblocks give rise to a lot of conspiracy theories and provide fodder for us to react out of fear instead of using good judgement.  I definitely saw some fodder for fear in this blog post that popped up in my facebook feed.

The author does start out with some grim statistics about our health, and does actually provide a link to the article.  One of the things I found interesting, however, is that while the author of the blog post focuses solely on diet, the authors of the linked article point to a multitude of factors that influence our health, including smoking, not wearing seat belts, limited access to health care, etc.  Sure, diet plays a role, but to use those set of statistics and then only point to diet is not evidence based at all.  On a related note, she also talks about how the main problem in Holmes County, MO is a lack of nutrition education.  There might be a contributing factor, although we don't know for sure without some more information.  I will throw my own anecdote in here and say that if lack of education was the only problem, then all of my patients would be slim with no health problems at all (pardon the sarcsam).  Sure, people do need to know what to look for on labels, but they also need the desire to want to change their habits, the funds to purchase the food, the cooking skills to prepare healthy food, access to healthier choices, etc.  I wish we could point to purely one thing (aka diet) as the solution to all our health/longevity issues, but it's more complicated than that.  I also wish that education was the only thing needed to get all of us healthier, but there needs to be more support involved.

There is also an implication that the "Big Food" companies are all trying to kill us.  Since we supposedly are in a free-market economy, the companies are trying to make money, and they will use whatever techniques they can to do so.  Because of this, I can see the case for claiming "apathy" about the health of Americans, but are they out to get us?  Maybe not.  I don't agree with a lot of techniques personally, but I don't know why they are a surprised to anyone or why there was some sort of expectation that these big companies were suppossed to "lead" the discussion on healthy foods?  I think there is definitely value in "voting with our dollars" to change what they make and sell (opinion), but we also going to have to make it a money issue for change to happen.  I also don't think that "it was banned in other countries" is an evidence based argument, particularly when there are drugs (like Tylenol with Codeine) that are available elsewhere but not in the United States.  It should give us pause, but it's not an evidence based argument.

As far as the ingredients that are used here vs. overseas, I find it interesting that she is pointing the finger at these mysterious ingredients as the cause of all of our ills, but then chooses to compare our products to ones that are found in the UK.  A quick internet search indicates that obesity and type 2 diabetes rates in the UK are actually comparable to the rates in the United States (Link), so we can't point to those ingredients as the main cause just by using those comparison's there.   Of the other comments that are made, the only one that she actually has any good evidence for is that hydrogenated oils/trans fats have been implicated in cardiovascular disease and insulin resistance.  There just isn't any good evidence for GMO's, MSG, etc causing problems (1, 2).  Even when she talked about the Mayo Clinic claiming that certain food dyes "caused" hyperactivity in children, if you follow the link, their answer is really close to a "we don't really know."  In my very limited experience with pediatric nutrition, usually when parents "cut out" all the artificial colors and flavors and claim that they did experience a change in their children's behavior what they were doing was switching from a low nutrition diet (aka inadequate protein/vitamins/minerals) to a much more nutritionally adequate plan.  Was it really just the artificial coloring that was doing it, or was it just eating like we are all suppossed to be eating that caused a change?  Or was it parents learning to parent differently since their child received a diagnosis?  Or was it all of the above?  More evidence needed please.

Are any of the convenience/fast foods that were chosen actually healthier without the "red" ingredients, as in, would we want to eat those foods on a regular basis anyway?  Probably not, as the foods mentioned didn't really have anything that we need (with the exception of the little bit of fiber in the oatmeal).  Everything mentioned was pretty much devoid of nutritional value and a source of un-needed calories and refined carbohydrates.  That right there should be enough evidence that we need to limit or avoid those foods, we shouldn't have to start using scare tactics using information that may or may not be true.  And if you are like me, you don't want to spend the money on diet sodas, etc that are giving you little to no bang for your buck anyway.

Take home message--Most convenience foods and fast foods are empty calories--foods devoid of nutrition that really provide nothing but a more "convenient" way to get more calories.  That should be enough of a reason to limit/avoid them.

A Healthier Cocktail?

If there is one thing we human beings are good at, it's rationalizing our choices, or a process known as cognitive dissonance--we know we shouldn't be doing something but we will do it anyway, and then try to come up with all kinds reasons why our choice was justifiable.  And that's what I thought of when I read this article about some restaurants are now creating and marketing "healthier cocktails."

What's wrong with cocktails when drinking alcohol in moderation doesn't seem to be a problem?  Well, first of all, not everybody practices moderation, period.  Second of all, cocktails by their very nature tend to be empty/un-needed calories that mostly serve to thwart your weight loss efforts instead of helping.  Third, if you've got diabetes or one of those insulin-resistant conditions that I am so fond of talking about, you are probably getting way more carbohydrate in those drinks than you might initially suspect, and if you already have wildly swinging blood glucose levels any alcohol might make that worse.  Fourth, since people have to do a little more digging to figure out the carb/calorie content of those drinks, it's easier to allow that information to go by the way side when you're concentrating on the nice restaurant that you are at.   So, those of us that have done even a little bit of research into why that cocktail may not be so good for us, but still like to have them, might start to do a little rejoicing when you see "healthier cocktail."

Until I come along and ruin it for you.  You asked for it by reading my blog.

If you are hoping to save on some calories by consuming some of these cocktails, I don't think your in luck.  If I did my calculations correctly, the recipe for the cocktail recipe they gave in the article is still going to run about 150-163 calories, about the same as a can of soda.  Granted, that's less than margarita which could run 400 calories plus, but if you have more than one ("It's a healthy cocktail!") it starts to add up.  I also noticed that a lot of the cocktails mentioned seemed to have fruit juice, and even if it's "fresh pressed" you are still running the risk of allowing some extra carbohydrate in there.  And those cocktails that promise to "boost your immunity?"  I've already talked about how that doesn't mean what you think it means.  Now you might actually get some antioxidants and other good things by having that beet juice, but you could also just eat the beets, or whatever other vegetable they are putting in there and not get the extra calories.

My suggestion is to first learn to say, "I am drinking a cocktail because I damn well want to."  (The choice of "colorful metaphors" is up to you).  My other suggestion, if you really are concerned about the calories and carbohydrate is to spend a little time on the internet ahead of time and research which ones have the least amount of carbohydrate and calories, or better yet, just make your own at home so you can control what goes in it.  (Boyfriend of SkepticRD makes a damn good whiskey sour with Splenda).  And of course, plan ahead of time how much you are going to drink, and maybe even ask a buddy to help you keep it in "moderation."

Take home message--Quit rationalizing and do a little homework before you drink.  And enjoy it in a way that you don't regret it later.

Pre or Probiotics?

You've probably heard that we have more "bacterial" cells than we have human cells, or some variation of this statement (Link), and this seems to have a decent amount of evidence to back that up.  What we are still learning about, however, is how disruptions in what is termed the "microbiome" can impact our health and health indicators like weight.  In my news feed I came across one particular article that indicated that pre-biotics could help in the "battle" against obesity.  But what are prebiotics?

Those of you who have been following this blog for a while probably remember an earlier post on probiotics, and the basic message was that taking probiotics does not change your gut microbiome for the better because your body sees them as foreign objects and tries to get rid of them as fast as possible (the exception being that it does seem to help anti-biotic related diarrhea if probiotics are started at the same time as the anti-biotics).  Pre-biotics, on the other hand, actually help the growth of beneficial bacteria that is already there.  Think of the beneficial bacteria in your gut as potted plants and pre-biotics as a type of "plant food" such as Miracle Grow.   We don't know yet if changing your gut flora will actually help you lose weight (i.e. change the way you absorb nutrition/calories from food), but it certainly doesn't seem to hurt to keep growing the good stuff.

Now, one of the problems that I have whenever prebiotics are mentioned is that someone is usually trying to sell me a supplement of some kind, similar to the way people try to sell me other vitamin supplements.  There are foods that have prebiotics in them, and they are usually plant based.  (I liked this quote from, oddly enough, Wikipedia, which states "Referring to a food as "a prebiotic" is no more accurate than calling a food 'a vitamin'.")  Usually if you try to eat a variety of vegetables (aim for as many different kinds of vegetables as you can) you will increase your pre-biotic intake, and these particular vegetables (jerusalem artichokes, asparagus, jicama, red and white onions, leeks, garlic, spinach, dandelion greens and tomatoes) have a somewhat higher content. 

For people who tolerate grains and legumes you can also get pre-biotics from these foods as well, but I would really rather people concentrated on vegetables first.  In my experience/in the population I work with (anecdote alert!), people do not check carefully enough to make sure that the bread, etc really is whole grain and they get essentially empty calories and no fermentable fiber.  The other problem that I have (and remember, my specialty is diabetes) is that people wind up way overdoing their carbohydrate intake through the use of bread, pasta, cereal, etc even if they were careful to get the whole grain.  Same thing with legumes--if you have diabetes or any other insulin-resistant conditions you will carefully have to watch the amount to keep your blood glucose/insulin levels in check.  Remember, more at one time is not usually better even if you are eating the "double fiber" bread.

There's one other consideration when it comes to pre-biotics, particularly if you are taking a pre-biotic supplement or eating an pre-biotic supplemented food (Inulin is usually the pre-biotic of choice for supplementation).  Pre-biotics are also called "fermentable fibers" and guess what fermentation produces?  That's right, it produces flatulence, more commonly called "gas."  The internet does have some fairly entertaining stories about the so-called "Jerusalem Fartichokes", but if you don't have pets to blame it on you could be in deep trouble.  Even if you can stand the smell (and the noise), if you have IBS, like yours truly, you might find the "gas pains" rather hard to cope with.    So, if you are choosing to use a supplement, a high inulin food, or a pre-biotic supplement food, start with very small amounts to see how you tolerate it and/or cook the food well.

Take home message--eating more vegetables and fermentable fiber foods could help change your gut microbiome.  Probiotics are of limited use only.

Gluten or Something Else

One question/comment that I get a lot, when I mention that I eat gluten free (and they know I'm a dietitian), is something a long the lines of "Oh, is that healthier?" (meaning that "you eat this way, so it must be better, right?") 

As much as I would love to claim myself as the perfect shining example of health, I usually have to say "well, it's more complicated than that."  (Most people who know me now realize they will not get a yes or no answer out of me, and some of them even appreciate it!  They also realize I'm no more perfect than anyone else).  I did come across this blog post in the NYT the other day, however, that does give a pretty good overview of what we do and do not know about gluten, and who is and who is not taking a scientific approach.

We do know that people with true celiac disease do need to avoid gluten if they ever hope to recover a functioning digestive system.  People with conditions like dermatitis herpetiformis also must avoid all sources of gluten if they ever want that rash to go away.  That's a definite "yes, it's healthier" for people with these conditions.  But for some of us it gets a bit murkier.  There are no good tests for gluten sensitivity like there are for celiac disease (and even then, people have to make sure they have been on their regular gluten-full diet for at least two weeks for those tests to be accurate).  And sometimes people feel better and lose weight when they "gluten-free" simply because their diets got healthier overall.  I remember one patient who came to me with dermatitis herpetiformis who did lose about 25-30 pounds after he cut out gluten (he was glad to lose the weight), but since he didn't want to pay for the more expensive gluten free pastas, etc he wound up eating grilled/baked meats, more vegetables, and the occaisional rice/corn tortillas to fill in the gaps.  In other words--he had a significant calorie reduction and he started eating higher quality food and found it satisfying.  Had he been willing to spend the money on gluten free bread, gluten free pasta, gluten free crackers, etc, I highly doubt he would have seen an improvement.   So, if someone winds up cutting out gluten and loses weight, and oh-by-the way I cut way back on my carbohydrate intake and eat more nutrient dense vegetables, maybe it wasn't the gluten.

One of the double blind studies indicated that a gluten free diet seemed to help people with irritable bowel syndrome. (IBS) But, it may not have been the gluten that causes the problems, there are other things found in wheat, namely fructans, that some people have trouble digesting and may cause symptoms.  And with the people who claim relief of arthritis when eliminating wheat; once again we only have anecdotal evidence.  If someon with arthritis wants to eliminate wheat, and subsequently improves the quality of their diet in other ways, and has a relief of symptoms--if it isn't broken I won't try to fix it, but I can't claim proof at this point.

Now, for those of who do have gastro-intestinal problems like the ones mentioned in the IBS article, please tell your doc so that you can be tested for serious conditions like celiac.  If you and your doc do think your GI problems are diet related, the best approach that we have is to follow the Low FODMOPS plan.  This particular plan severely limits foods that contain compounds that are poorly absorbed by the body, draw more water into the bowel, and cause "gas" through increased fermntation.  You get to follow this diet for 6-8 weeks (hopefully with the help of a qualified person like yours truly!) and see if your symptoms improve.  At the end of the six weeks you start adding certain things back in (one at a time!) and see if your symptoms worsen.

One of the other complaints about gluten free diets (besides the expense of gluten free crackers, etc) is that some health care professionals are worried about nutrition deficiencies.  I understand their concern--because some people who are eating a lot of processed food just keep eating their processed food, only now they don't even have a little vitamin fortification from whole wheat bread, etc.  You have to not just go gluten-free, you actually have to make sure your are getting enough nutrient dense vegetables, protein, and good fat.  I also know that some people think that since not all people have genetically adapted to have gluten in our diet that no one should eat it--this sounds like it's based on an assumption that we have stopped evolving/adapting over the past 10,000 years and that doesn't appear to be the case either as some people do seem to be able to eat dairy and grains without an issue.

Take home message--If you have GI complaints and/or a weird rash that won't go away, talk to your doctor about the possibility of getting tested for celiac disease (particularly if these are in your family history).  If all other problems are ruled out and your doc labels you with IBS, you can try an elimination diet to see if your symptoms improve.  If you know you are overeating on bread, pasta, etc and having trouble losing weight, you are going to benefit from limiting the processed food period.

Pickles and Garlic?

People have a lot of interesting ideas about what will raise or lower their blood glucose levels.  The other day I was dealing with a particularly trying individual whose blood glucose levels were so high his glucometer (blood glucose measuring device) would only read "HI," meaning that his readings were over 600.  This is the point where I as a medical professional plead with the person to go to the hospital as he is risking dehydration and death, but he was agreeable to increasing his insulin dose slowly day by day to get his readings under control.* He also said he was going to start "eating pickles and garlic to bring my sugar down, just like my daddy said."

*I'm sure there are some people who are going to read that line and start accusing me of just wanting to give people medicine instead of going the "natural route."  First of all, in a situation like this one--having a person just change their diet to lower their blood glucose levels is the equivalent of standing over someone who is having a heart attack and saying "Dude, you really need to eat more vegetables" instead of dialing 911 and/or performing CPR.  Second of all, people have to actually FOLLOW a reduced carb meal plan to lower their blood glucose and this guy was clear he knew all about it and wasn't going to do it anyway.

Anyway, I've heard the pickles and/or garlic myth before, and I think I have a pretty good handle on where that might have come from.  As far as the pickles go--if you have someone who has been eating a lot of salty tasting snacks like potato chips or pretzels, and they substitutes pickles, they have just went from a high carbohydrate consumption to a lower carbohydrate consumption and the removal of the all of that carbohydrate probably is what helped.  Nothing magic about the pickles.  Now, interestingly enough, there is some limited evidence that regular consumption of vinegar (which is in pickles!) might result in lower post meal blood glucose levels (Link); but we certainly don't know if a steady dose of pickles after your dose of potato chips will continually control your blood glucose.

Garlic is a different story in that there seems to be no evidence that eating garlic or using it as a supplement will actually help lower your blood glucose. (Link)  Now, once again, some people will just eat garlic as is, and other people are probably going to use it as a flavoring on their meats or vegetables.  If using garlic as a flavoring helps you eat more vegetables and less carbohydrate, by all means add the garlic, but don't expect it to magically bring your blood sugar down.

Take home message--substituting pickles and garlic on vegetables for high carb snacks and high starch meals could help keep your blood sugar from going to high, but it won't bring it down if it's already high.

Obesity Mythology

I'm feeling a little bit happier about nutrition reporting today, and it's because I saw this article: Myths of Weight Loss are Plentiful and read this first paragraph:
"If schools reinstated physical education classes, a lot of fat children would lose weight. And they might never have gotten fat in the first place if their mothers had just breast fed them when they were babies. But be warned: obese people should definitely steer clear of crash diets. And they can lose more than 50 pounds in five years simply by walking a mile a day."

I was happy because it indicated someone else is trying to dispel myths and not trying to sell you his/her own mythology.    And I was happy that there was a link to the actual article itself so that people could compare what was actually said versus what was reported on (Link), as sometimes they are not the same thing.    And I also liked that one of the authors of the study admitted that everyone is vulnerable to logical fallacies, including confirmation bias, if we are not careful.  It gave me hope that there are still people who are good at communicating their skepticality out there.

One potential pitfall that I did see in reading the orginal article, however, is that people would look at one of the points (e.g. the one on school physical education programs not preventing obesity) and conclude that these behaviors have no value at all.  We have to remember that the authors of the study were looking at obesity, period, and that we can't say "school physical education programs have no value at all."  In other words, just because a particular behavior or program can't help with one thing doesn't mean that it is not useful at all, it just needs to be studied from another angle or other outcomes need to be looked at.

I also wanted to highlight this statement in the conclusion as well: "While we work to generate additional useful knowledge, we may in some cases justifiably move forward with hypothesized, but not proved, strategies. However, as a scientific community, we must always be open and honest with the public about the state of our knowledge and should rigorously evaluate unproved strategies."  In other words, sometimes we do have to move forward using what we know while acknowledging there is always someone out there working for a better designed study to improve our knowledge, because that's what we do in science.  And we all have to continually stop and re-evaluate where our own biases might be.

Dude, where's my Pancreas?

I suppose on some level I should be grateful for celebrities, because without them I would have less blog material.  Like the story this week on Ashton Kutcher's hospitalization and the subsequent commentary that went along with it.  Let's look at what's wrong with this story, shall we?

First of all, we don't know by reading this article, or anywhere else, what he really had.  The only indicators that he gives is the abdominal pain and his "pancreas levels were out of whack."  I think that he might be referring to the levels of "pancreatic enzymes" perhaps?  So, quite possibly, given his abdominal pain and elevated pancreatic enzymes it is quite possible he had pancreatitis, but we don't really know as we are not privy to the rest of his medical history.  And even if we had all of that, you can't just diagnose because you read something on the internet.

Second of all we have the logical fallacy of "post hoc ergo propter hoc" or "after this, therefore because of this."  In other words, he went on a crazy diet, had problems, therefore it must be part of the diet.  Once again, we don't know all of the information about Mr. Kutcher's medical history, what other food/beverages he might have been injesting (or not injesting) before/during his all-fruit diet, what (if any) medications he was taking, what (if any) herbal products he was using, what his lab work really was like, etc.  So we can't assume that whatever he had was exactly a direct cause of the diet.

Third, let's pretend for a moment that he did really have acute pancreatitis.  Could the "all fruit diet" actually cause pancreatitis?   The quote from the dietitian referenced in the CNN article almost implied that it could, but that is highly unlikely (and she might have been misquoted anyway).  Yes, your pancreas does produce insulin, and yes when you are eating a lot of carbohydrate your pancreas will make more insulin (the pancreas also does other things like produces enzymes to help us digest fat).  But if hyperinsulinemia (aka. over production of insulin) caused pancreatitis, then everyone with pre-diabetes and early stage Type 2 would have acute pancreatitis.    Pancreatitis is usually caused by gall-bladder problems or chronic alcohol use.  Some people have had acute pancreatitis because of having triglycerides over 1000 mg/dL (although you are considered at risk if they are >500 mg/dL), and high triglycerides can result from elevated insulin levels (although usually at that level we also have some genetic disorder and/or medication reactions to thank for that)--so I suppose you could stretch it to say that he might have had elevated triglycerides.    But once again--that's just a leap, we don't have all the information.

So, yes, a diet that consists only of fruit can cause other problems--mainly a lack of protein and essential fats.  Was the diet the cause of the illness of the star of  "Dude, Where's My Car?"  Probably not, but once again, we don't have all the info.  And if you take medical advice from a celebrity?  You probably need more help than I can give you.  And that "mucusless" diet that Steve Jobs was following?  That is another post for another day.....