Tag Archive for: nutrition

Supplements: Helpful or Harmful?

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About a week ago when a press release about a study published in the Journal of American Academy of Cardiology stated that vitamins and minerals don’t seem to help the health of those people who use them; they should stick to getting nutrients from the food they eat. As you can imagine, I got questions from many readers.

For those of us who use dietary supplements, have we been wasting our money? Or maybe as part of the study showed, we’re doing ourselves harm? Don’t throw out your supplements just yet.

The study was a meta-analysis that examined randomized controlled trials (RCT) since the U.S. Preventive Services Task Force (USPSTF) Recommendations for Dietary Supplements was published in 2012. They examined RCTs that used multivitamins, vitamins and minerals, and antioxidants to determine their affect on health variables related to cardiovascular disease and overall mortality.

Was the study done well? Yes and no. They included RCTs that examined the use of specific supplements and health outcomes. The problem is that they didn’t examine the quality of the supplements used in those studies. That’s a significant problem but not the only one. More on this Saturday. Until then, regardless of the headlines, take your supplements if you know why you’re taking them.

What are you prepared to do today?

Dr. Chet

 

References: Jenkins, D.J.A. et al. J Am Coll Cardiol. 2018;71(22):2570–84.

 

Health Headline: Diet and Hearing Loss

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Researchers examined nutrition data collected between 1991 and 2013 in the second Nurses Health Study to examine whether adherence to a healthier diet reduced the risk of hearing loss. They developed a scoring system for three dietary approaches: the Alternate Mediterranean Diet (AMED), the Dietary Approaches to Stop Hypertension (DASH), and the Alternative Healthy Eating Index-2010 (AHEI-2010). They also gave the subjects a hearing health questionnaire to ascertain hearing loss in 2009 and 2013. The researchers divided the diet scores into quintiles and examined the trend across increasing adherence to each of the three diets as determined by the scoring system.

Researchers reported that as the adherence to each diet increased, hearing loss decreased. Those subjects who adhered to their diet best reduced their hearing loss by as much as 30%.

Headline worthy? A split decision. I’m in favor of any reason for nurses or anyone else to eat a healthier diet with more vegetables and fruit.

Why not headline worthy? The first issue was use of the food frequency questionnaire, which relies on recall for the number of typical servings of over 150 items during the past year. Yes, you read that right; the questionnaire asks, for example, how many times you had chicken in the last year and how big was the serving. Maybe you could answer questions like that accurately, but I couldn’t. And as the old axiom about data goes: garbage in, garbage out.

Second, it used a poorly validated self-report of hearing loss from fewer than 700 subjects in just two studies. That’s good enough for a pilot study, but not good enough to make a recommendation.

Third was that when examining the median values for scores in the highest quintile across all three diet assessments, adherence was no better than 67% and as low as 50%. That means 33–50% of the time, the subjects ate foods that were not part of each diet. What made up the other half to a third? Maybe that was the secret to success.

So while these are promising results, they simply point the way to a bigger, better study to see if a better diet makes a significant difference in reducing hearing loss. However, if fear of hearing loss will motivate you to eat healthier, that’s a good outcome. But if I suspected hearing loss to be in my future, I’d take other steps in addition to eating better.

The Bottom Line

That’s my look at last week’s health headlines and the science behind them. In every case, the science did not merit the conclusions. The rush to publicize results gets headlines, but really? That’s all it does.

We can say that they provide interesting results that need further study. Even without complete info, you could take positive steps such as eating better to perhaps help avoid the conditions studied—you’ve got nothing to lose by eating more fruits and veggies.

What are you prepared to do today?

Dr. Chet

 

Reference: The Journal of Nutrition, nxy058, https://doi.org/10.1093/jn/nxy058.

 

Health Headline: Ketogenic Diet and Type 1 Diabetes

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Researchers wanted to examine the blood sugar control of type 1 diabetics who use a very low carbohydrate, high-protein, moderate fat ketogenic diet. The diet was developed by Dr. Richard Bernstein, himself a type 1 diabetic. They used a unique study design: they requested volunteers from a Facebook group of children and adults who adhere to the Bernstein Diet. Over 300 volunteers completed an online survey about their diagnosis and diet. The diagnosis of type 1 diabetes was confirmed from medical records from a follow-up survey of medical staff.

This was a rigid ketogenic diet with no more than 30 grams of carbohydrate allowed per day. The average intake was 36 grams carbohydrate per day. The better the control of carbohydrate intake, the better the HbA1c score, with a mean of 5.7%. Remember, these were type 1 diabetics; there are many type 2 diabetics who don’t control their HbA1c that well. I think this study illustrated the potential of nutrition in affecting a disease system. One interesting aside was the healthcare professionals treating the patients seemed indifferent to the dietary approach regardless of the results.

Headline worthy? Yes, in context. Close to half the subjects did not provide access to medical personnel so the researchers relied on the initial subject surveys for information. They also had no access to any dietary records to confirm the diet. Still this was a unique way to use social media to gather information. The study has to be confirmed using traditional research design to assess the variables. But this approach examined people who live this diet on their own or with their children. That can provide insights that might be missed if the study were conceived by a group of research professionals discussing the question around a table.

What are you prepared to do today?

Dr. Chet

 

Reference: Pediatrics. 2018. doi: 10.1542/peds.2017-3349.

 

“My Doctor Told Me”

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I get asked health questions all the time about weight loss, fitness, diet, and more. If a physician told the questioners something they should or should not do, they will let me know, and then I know my job just got harder. That’s why “my doctor told me” are four of the most powerful words I ever hear.

The problem when it comes to nutritional recommendations, which can include both diet and supplements, is that physicians are not trained in the basics of nutrition. They may have read a summary about a high-fat diet or a multivitamin and tell their patients not to try this or take that, but they have no basis of training to know whether the study was well done or not. Even when they get the training, the specter of evidenced-based medicine (EBM) raises its head.
 

The Problem with Evidence-Based Nutrition

I decided to check out the Gaples Institute website. There’s general information about a healthy diet for patients. There’s also a course that healthcare professionals can take online to learn about nutrition. I read the brochure that’s available for physicians to find out what they will learn in the four modules of the course.

It’s nowhere near enough. Four 45-minute modules? I’ve been studying nutrition for 30 years, and there’s still so much I don’t know; it’s impossible for them to learn enough in three hours to reliably counsel their patients. In addition to that, the Gaples Institute uses the same low-fat approach to reducing the risk of heart disease that has been used for the past 50 years. And how has that worked for us? We have the highest obesity rate we’ve ever had.

Yes, physicians should understand there are better fats than others. Yes, physicians should understand that refined carbohydrates and deep-fried foods should be limited. But because the materials use data from large epidemiological studies that fit the EBM criteria, this is not real nutrition training. It provides them a single way to teach their patients, and that’s not providing any real nutrition training.

To say I was disappointed would be an understatement. Physicians need in-depth nutrition training, not a course that teaches a specific dietary approach to disease prevention. That doesn’t mean the Gaples approach won’t help some patients, but it ignores alternative approaches that might also help patients. While I said that “my doctor told me” were the most powerful words I hear from people, I also know that if they hear something they don’t like, they won’t do it, evidence based or not. Knowing what to do next requires real training in nutrition. That won’t happen in a three-hour course.
 

The Bottom Line

We’ll just have to wait and see what happens with nutrition training for physicians. It’s not really their fault; there’s so much to learn about treating disease, it leaves little to no time to teach prevention. For now, that’s left up to us as patients. While nutrition is complicated, you can always count on these six words to help you prevent degenerative disease:

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

References:
1. JAMA Online. 4/11/2018.
2. Arch Intern Med. 2011;171(14):1244-50.

 

Physicians as Teachers

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As the interview in JAMA continued, Dr. Devries continued talking about the lack of training and why it was a problem in his mind. He cited a study published in 2013 by the U.S. Burden of Disease Collaborators which concluded that the leading risk factor for degenerative disease and mortality was a poor diet. A poor diet! He suggests that because physicians are so poorly trained in nutrition—meaning not at all—their patients are suffering the consequences.

Dr. Devries became frustrated and together with others formed the Gaples Institute for Integrative Cardiology, a non-profit that aims to teach the public and physicians about diet, exercise, and the mind-body approach to heart health.

For the rest, it’s not just giving a patient a couple of handouts with healthy diet guidelines. Physicians have to somehow become the teachers. For that, they need training. But even before training can be addressed, insurance companies must be willing to pay for this type of physician-patient time—or any time beyond the 15-minute consultation limit imposed by many healthcare businesses. While the insurance companies may provide websites and materials and even some training with dieticians, it doesn’t carry the power the physician would have.

No real nutrition training of physicians, no hands-on nutrition training by physicians, yet what physicians say resonates with their patients in ways they don’t realize. On Saturday I’ll tell you the four most powerful words I hear about health.

What are you prepared to do today?

Dr. Chet

P.S. The fiber drink recipe I talked about last week is now available on the Health Info page at DrChet.com.

 

References:
1. Arch Intern Med. 2011;171(14):1251-57.
2. JAMA. 2013;310(6):591-606. doi:10.1001/jama.2013.13805.

 

A Doctor’s Nutrition Training

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“Essentially zero.” That’s the answer a physician gave in an interview when asked how much nutrition he received in medical school. The lack of substantive training continued all through his internal medicine residency and specialty training. His expertise? Cardiology. What’s worse is that he said that nothing has changed since.

The interview with Dr. Stephen Devries was recently published in JAMA. He goes on to talk about how he was well-trained to deal with cardiac events when they happened. His frustration came with his inability to do much to help his patients. They would return with the same serious cardiac problems. Why? Because nothing changed in their lifestyle to help prevent reoccurrence. They didn’t learn anything because he didn’t teach them anything about how to do that.

I’m going to talk more about this interview, but here’s a challenge for you. The next time you have a doctor’s appointment, whether general practitioner or specialists, ask them what type of nutrition training they had when they were in medical school or in their residency. It will be interesting to find out their answers.

Reminder to all Insiders: the monthly Conference Call is tomorrow night. If you’re not an Insider yet, there’s time to join before the call.

What are you prepared to do today?

Dr. Chet
Reference: JAMA Online. 4/11/2018.

Bioavailability Ends with Bioactivity

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Here’s where we stand: we’ve digested a nutrient and it’s been absorbed into the bloodstream. How is it going to be used? How do we get the benefit of vitamin C, magnesium, alpha-carotene, or caffeine? Let’s take a look.

Many target cells have receptors that are specific to a nutrient, like a wrench that fits only one size of bolt. For example, when blood sugar rises after pasta is digested and absorbed, insulin is released from the pancreas. Insulin will attach to a specific insulin receptor on the cell membrane, and that will allow a glucose molecule to enter the cell to be used. Cells also have receptors for vitamin C to be absorbed into cells.

That’s fairly straightforward. The next step would be actually performing a function once the nutrient enters the target tissue. Let’s look at caffeine for example. There’s a genetic factor; one version of a gene can process caffeine quickly while a mutation of that gene processes it slowly. I can drink coffee and immediately go to sleep. Others may process it slowly and may not be able to sleep in the evening after a cup of coffee for lunch. Same nutrient, different effects on different people.

In addition, there are numerous enzymes that help make chemicals such as hormones or structures such as cartilage. If enough of an enzyme isn’t being manufactured or it’s blocked from being utilized, that can have an impact on how well a nutrient works. An example would be insulin; if cells are not producing enough receptors, or the receptors are resistant to insulin, blood sugar would rise. That leads to overall insulin resistance, one aspect of being prediabetic.

Another example would be the manufacture of glucosamine. The process requires fructose-6-phosphate and the amino acid glutamine; the first is a result of the breakdown of sugar while the later is the most prevalent protein-building amino acid in the body. The manufacture of glucosamine also requires an enzyme. If a person doesn’t make enough of that enzyme, that affects the production of glucosamine which then impacts the production of other forms of connective tissue such as cartilage, ligaments, and bone.

The Bottom Line

Every day there are new nutrition products introduced that are supposed to be better for you because more nutrients are available, but nutrition just doesn’t work that way. As I’ve tried to show you this week, the problem is that it isn’t quite as simple as what you see in Internet ads. Nutrients have to be digested, absorbed, and used by the body, and things can go wrong at any step along the way. Each individual’s body is unique and comes with its own idiosyncrasies and difficulties, and that’s what makes nutrition so complicated.

Maybe you’re thinking, “What’s the point if so much can go wrong?” What you have to remember is that most of the time everything works just as it should; not everything related to bioavailability goes wrong in every person. It’s also a matter of degree—maybe absorption will be cut by 50% or activity reduced 10%. I want you to understand why some nutrients won’t work as expected for a particular person, and why claims of better bioavailability aren’t a guarantee.

Yet we’re still here, aren’t we? We’re here because our ancestors survived. To steal a line from “Jurassic Park”: Nature finds a way.

What are you prepared to do today?

Dr. Chet

 

Reference: http://bit.ly/2raDviy

 

Bioavailability Continues with Absorption

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On Tuesday I talked about some of the processing required to get nutrients ready for absorption. The next phase of bioavailability is the absorption of the nutrient from the gut into the bloodstream. Let’s look at what’s involved.

The absorption process occurs via the intestinal epithelial cells and they vary in size and function in the small and large intestine. Some nutrients such as lipids may use a passive process to be absorbed. Sugars, amino acids, and others will use an active process involving transporter enzymes as well as using energy to be absorbed. Vitamin B12 absorption is much more complicated; it requires something called intrinsic factor and then is passed to another protein carrier for absorption.

Here’s where absorption can go wrong. Maybe you don’t produce enough of a transporter enzyme for one or more amino acids. Perhaps you have a condition such as irritable bowel syndrome, and some of the areas where absorption occurs are missing. There are more scenarios related to absorption, but they can all lead to a lack of bioavailability. Then there’s the fact that all our bodies are the tiniest bit different. Because most absorption studies are done with simulations of the digestive system cells, product claims of greater bioavailability can easily differ from what actually goes on in your digestive system.

Let’s say that you have digested and absorbed a nutrient. Does that mean your body will actually be able to utilize the nutrient? That’s the topic of Saturday’s Memo.

What are you prepared to do today?

Dr. Chet

 

Reference: http://bit.ly/2raDviy

 

Bioavailability Begins with Digestion

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Last Saturday’s Memo introduced a new concept: a systems approach to nutrition. One term that gets bounced around a lot related to dietary supplements or different types of food is bioavailability. Claims are made that “this form of our supplement is 10 times more bioavailable than that form.” It sounds so simple, right? It’s not—we’ll spend this week looking at all that’s involved in bioavailability. It begins with the entire digestive system.

Digestion is the process of breaking down a food or nutrient for absorption. There may be plenty of a nutrient consumed, but it has to be broken down into a form that can be absorbed. That begins in the mouth by chewing, and then the action really heats up in the stomach; acids are released to break the food into smaller molecules, if required. After leaving the stomach, the digestive enzymes begin to work on the food to continue the process. If it’s a nutrient from a supplement, it may be absorbed as it is or it may need to be modified biochemically. As the nutrient continues through the small and the large intestine, it may require a modification by bacteria before it can be absorbed.

There are many points in the process that can affect absorption. Does a person’s stomach release enough acid? Does the pancreas make enough digestive enzymes? Is there enough food that provides chelating agents for minerals? Is the microbiome healthy enough to continue the breakdown of the nutrient? You can see how the system can be affected in numerous places. But we’re not done yet. On Thursday, we’ll talk about absorption.

What are you prepared to do today?

Dr. Chet

 

Reference: http://bit.ly/2raDviy

 

I’m Recommending a Broccoli Bath

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This week’s final question is whether cooking destroys the nutrients in vegetables. If it does, is there any method better than others for preserving the nutrient content? Let’s take a look.

Researchers examined three cooking methods with several vegetables including broccoli. The methods were boiling, sous-vide cooking, and water immersion cooking at temperatures below 212 degrees F, water’s boiling point. The objective was to see the effect on phytonutrient content of each vegetable.

Your first question is probably this: what is sous-vide cooking? I didn’t know even after all the cooking shows I’ve watched. Sous-vide is French for under vacuum. The general idea is that the food is placed in a plastic bag, air is removed by vacuum, and the food is cooked in a water bath at relatively low temperatures (130–150 degrees) for a longer period of time. A low-tech alternative is to place the vegetables in a plastic bag, immerse the bag in water until the air escapes, and submerge it in a low-temp water bath during cooking.

Which worked best? Sous-vide cooking preserved chlorophyll, carotenoids, phenolic content, and antioxidant activity to a greater extent than boiling for all of the vegetables tested. Second was cooking in hot water below the boiling point (150–160 degrees). The lower temperature improved the qualities of the samples cooked in water including the color of the vegetables. Boiling resulted in the greatest loss of the most nutrients.

If you usually microwave broccoli as we do, that’s a good method as well. It compares most closely with cooking vegetables at a low temperature as long as you cook it for as short a time and with as little water as possible. A microwave steamer is your best bet.

The important point is that cooking, including boiling, does not remove all beneficial nutrients. Probiotics will be sacrificed but some vitamins, minerals, and phytonutrients will still be in the cooked broccoli.

 

The Bottom Line

The bottom line on broccoli, as well as almost all vegetables, is that processing, whether by cutting, freezing, or cooking, will not remove the nutrients from the vegetables. The most important thing you can do is to eat them. The benefits to your body will be there.

What are you prepared to do today?

Dr. Chet

 

Reference: Food Chem. 2017 Feb 15;217:209-216. doi: 10.1016/j.foodchem.2016.08.067.