Vegans took a beating this week…

There are so many books and philosophies about the “right” way to eat, and things have changed over the last few decades.  Increasingly, the 2 million year history of our forebears’ diets is being used as observational evidence to support what our genetics are best suited to eat.  Check out his Washington Post link:

Sorry, vegans: Eating meat and cooking food is how humans got their big brains
By Christopher Wanjek
Vegetarian, vegan and raw diets can be healthful, probably far more healthful than the typical American diet. But to call these diets “natural” for humans is a bit of a stretch in terms of evolution, according to two recent studies. More…

Intriguing trends in neurological research gives hope for a wide variety of conditions

Seizures and Other Brain Disorders: Several neurological diseases currently have no real cure, and the only hope is for pharmacological interventions to ameliorate the symptoms or stem the inevitable.  These include some intractable seizure disorders, infantile spasms, Parkinson’s Disease, Alzheimer’s Disease, multiple sclerosis, chronic pain, autism, schizophrenia, macular degeneration, brain injury, stroke, depression, and migraine.  Since the brain has the highest lipid concentration of any organ next to fat tissue, it may not be surprising that deregulated lipid metabolism may be of particular importance for various CNS disorders.  Building on the long known positive effect of fasting, and the long known history of benefitsclinical experience,and suspected mechanisms of a ketogenic diet for intractable seizures (see also this 1998 and 2010 review on efficacy, a study using the Atkins diet on seizures, and a review on how the diet works), this diet is being looked at as a treatment paradigm for a diverse variety of other neurological disorders (see also this), even infantile spasmspain and head injury. A 2005 study revealed a benefit of ketogenic diet on cortical contusion.

Conversely, Scandinavian researchers have shown that Type II diabetes is associated with amygdalar and hippocampal atrophy ( a strong predictor of dementia), suggesting that Type II diabetes may directly influence the development of Alzheimer neuropathology.  Now, the recently published PATH study concluded that high plasma glucose levels, even within the normal range (<6.1 mmol/L) were associated with greater atrophy of brain structures relevant to aging and neurodegenerative diseases, the hippocampus and the amygdala. Consistent with this was a 2012 Mayo Clinic observation is that a dietary pattern with relatively high caloric intake from carbohydrates and low intake from fat and proteins may increase the risk of dementia in elderly persons.

Age-related Macular Degeneration: High fat intake, especially in the form of long-chain omega-3 polyunsaturated fats have also been shown in the Alienor Study, the Blue-Mountains Eye Study, and others to decrease the risk of macular degeneration.

Make no mistake though:  solid consistent research in the form of randomized, double blinded clinical trials intended to clearly outline the degree of benefit remain in the future, but, for those who do not have the time to wait, there is food for thought here.   Check these links out and talk to your doctor about your specific needs:

The Ketogenic Diet in Epilepsy and other Neurological Disorders:

  1. Front Neurosci. 2012; 6: 33.The Nervous System and Metabolic Dysregulation: Emerging Evidence Converges on Ketogenic Diet Therapy. David N. Ruskin and Susan A. Masino
  2. Front Pharmacol. 2012; 3: 59.Published online 2012 April 9. Prepublished online 2012 January 25. doi:  10.3389/fphar.2012.00059 PMCID: PMC3321471. The Ketogenic Diet as a Treatment Paradigm for Diverse Neurological Disorders. Carl E. Stafstrom and Jong M. Rho 

  3. Curr Neuropharmacol. 2009 September; 7(3): 257–268. doi:  10.2174/157015909789152164 PMCID: PMC2769009. Adenosine, Ketogenic Diet and Epilepsy: The Emerging Therapeutic Relationship Between Metabolism and Brain Activity. S.A Masino, M Kawamura, Jr, C.A. Wasser, L.T Pomeroy, and D.N Ruskin
  4. Epilepsia. 2007 Jan;48(1):43-58.  Anticonvulsant mechanisms of the ketogenic diet.  Bough KJ, Rho JM.
  5. J Neurosci Res. 2005 Nov 1;82(3):413-20. Age-dependent reduction of cortical contusion volume by ketones after traumatic brain injury. Prins ML, Fujima LS, Hovda DA.
  6. Subcell Biochem. 2008;49:241-68. Altered lipid metabolism in brain injury and disorders. Adibhatla RM, Hatcher JF.
  7. Epilepsia. 2007 Jan;48(1):31-42. Clinical aspects of the ketogenic diet. Hartman AL, Vining EP.
  8. Curr Neurol Neurosci Rep. 2006 Jul;6(4):332-40. State of the ketogenic diet(s) in epilepsy. Huffman J, Kossoff EH.
  9. Pediatrics. 2007 Mar;119(3):535-43. The ketogenic diet: one decade later. Freeman JM, Kossoff EH, Hartman AL.
  10. Pediatrics. 2002 May;109(5):780-3. Efficacy of the ketogenic diet for infantile spasms. Kossoff EH, Pyzik PL, McGrogan JR, Vining EP, Freeman JM.
  11. Adv Pediatr. 2010;57(1):315-29. Ketosis and the ketogenic diet, 2010: advances in treating epilepsy and other disorders. Freeman JM, Kossoff EH.
  12. Epilepsy Res Treat. 2011; 2011: 963637. Published online 2011 June 5. doi:  10.1155/2011/963637 PMCID: PMC3420518 The Ketogenic Diet 2011: How It Works. Keren Politi, Lilach Shemer-Meiri, Avinoam Shuper, * and S. Aharoni
  13. Epilepsia. 2008 Nov;49 Suppl 8:111-3. Diet, ketones, and neurotrauma. Prins M.
  14. Pediatrics. 1998 Dec;102(6):1358-63. The efficacy of the ketogenic diet-1998: a prospective evaluation of intervention in 150 children. Freeman JM, Vining EP, Pillas DJ, Pyzik PL, Casey JC, Kelly LM.
  15. Neurology. 2003 Dec 23;61(12):1789-91. Efficacy of the Atkins diet as therapy for intractable epilepsy. Kossoff EH, Krauss GL, McGrogan JR, Freeman JM.

On the Effect on Macronutrient Intake on Risk of Dementia:

  1. J Alzheimers Dis. 2012 Jan 1;32(2):329-39. doi: 10.3233/JAD-2012-120862. Relative intake of macronutrients impacts risk of mild cognitive impairment or dementia.  Roberts RO, Roberts LA, Geda YE, Cha RH, Pankratz VS, O’Connor HM, Knopman DS, Petersen RC.
  2. J Alzheimers Dis. 2010;21(3):853-65. Polyunsaturated fatty acids and reduced odds of MCI: the Mayo Clinic Study of Aging. Roberts RO, Cerhan JR, Geda YE, Knopman DS, Cha RH, Christianson TJ, Pankratz VS, Ivnik RJ, O’Connor HM, Petersen RC.
  3. Neurobiol Aging. 2006 Nov;27(11):1694-704. Epub 2005 Oct 26. Dietary intake of unsaturated fatty acids and age-related cognitive decline: a 8.5-year follow-up of the Italian Longitudinal Study on Aging. Solfrizzi V, Colacicco AM, D’Introno A, Capurso C, Torres F, Rizzo C, Capurso A, Panza F.
  4. J Nutr Health Aging. 2008 Jun-Jul;12(6):382-6. Dietary fatty acids, age-related cognitive decline, and mild cognitive impairment. Solfrizzi V, Capurso C, D’Introno A, Colacicco AM, Frisardi V, Santamato A, Ranieri M, Fiore P, Vendemiale G, Seripa D, Pilotto A, Capurso A, Panza F.
  5. Ageing Res Rev. 2010 Apr;9(2):184-99. Epub 2009 Jul 28. Dietary fatty acids in dementia and predementia syndromes: epidemiological evidence and possible underlying mechanisms. Solfrizzi V, Frisardi V, Capurso C, D’Introno A, Colacicco AM, Vendemiale G, Capurso A, Panza F.
  6. Curr Alzheimer Res. 2011 Aug;8(5):520-42. Mediterranean diet in predementia and dementia syndromes. Solfrizzi V, Frisardi V, Seripa D, Logroscino G, Imbimbo BP, D’Onofrio G, Addante F, Sancarlo D, Cascavilla L, Pilotto A, Panza F.


On Macular Degeneration:

  1. Invest Ophthalmol Vis Sci. 2011 Jul 29;52(8):6004-11. Print 2011 Jul. Dietary omega-3 fatty acids and the risk for age-related maculopathy: the Alienor Study. Merle B, Delyfer MN, Korobelnik JF, Rougier MB, Colin J, Malet F, Féart C, Le Goff M, Dartigues JF, Barberger-Gateau P, Delcourt C.
  2. Arch Ophthalmol. 2011 Jul;129(7):921-9. Epub 2011 Mar 14.  Dietary ω-3 fatty acid and fish intake and incident age-related macular degeneration in women. Christen WG, Schaumberg DA, Glynn RJ, Buring JE.
  3. Arch Ophthalmol. 2009 May;127(5):656-65. Dietary fatty acids and the 10-year incidence of age-related macular degeneration: the Blue Mountains Eye Study.  Tan JS, Wang JJ, Flood V, Mitchell P.
  4. Prog Retin Eye Res. 2005;24:87-138.  The role of omega-3 long-chain polyunsaturated fatty acids in health and disease of the retina. SanGiovanni JP, Chew EY.
  5. Arch Ophthalmol. 2007;125:671-679.  The relationship of dietary lipid intake and age-related macular degeneration in a case-control study: AREDS Report No. 20. Age-Related Eye Disease Study Research Group.
  6. Am J Clin Nutr. 2009;90:1601-1607. AREDS report 30, a prospective cohort study from the Age-Related Eye Disease Study.  Long-chain polyunsaturated fatty acid intake and 12-y incidence of neovascular age-related macular degeneration and central geographic atrophy. SanGiovanni JP, Agrón E, Meleth AD, et al; for the AREDS Research Group.
  7.  J Am Diet Assoc. 2008;108:1125-1130. n-3 fatty acids: Food or supplements?  Kris-Etherton PM, Hill AM.
  8. JAMA. 2005;294:3101-3107. Dietary intake of antioxidants and risk of
    age-related macular degeneration. van Leeuwen R, Boekhoorn S, Vingerling JR, et al.

Greenwashing: The 5 most useless terms on a food label

You’ve seen, “natural”, “made with…”, “whole grains”, “less than 100 calories”, etc.  Ever wondered what they can mean?  If you are reading them, chance are you are being “leanwashed”.  Check out a brief description of the Top 5 Leanwashing Terms of The Year here, and get cynical the next time you go grocery shopping.

On “Anti Nutrients”…

While the term “anti-nutrient” sounds like a science fiction concept, there are in fact a large number of elements in common foods that either neutralize or counter-act absorption of some of our better known nutrients, functioning as enzyme inhibitors (of proteases, lipases, and amylases), competitive inhibitors, chelators, or gastrointestinal irritants. Phytates, lectins, glutens, flavonoids, glucosinolates, oxalates, interfere with their absorption, or even contribute to nutrient losses.  Wikipedia provides a brief overview here.  So if you are wondering why you can’t get your iron stores up, or why you may have low stores of calcium or magnesium, or iodine, think of anti-nutrients that may be pervasive in your diet.

What is troubling is just how common these are, and especially in which foods they are commonest.  Natural, unprocessed foods, which would normally be thought of as healthy and a great source of a number of nutrients, are among the worst offenders as having high concentrations of anti-nutrients.  Nuts, whole grains, beans, and seeds….all good foods, yet high in phytates and other anti-nutrients.

So for your reading pleasure: Try a few good links,especially here, but also here, here, here, here, here, and here.  Or copy these links:


While most of us tolerate small amounts of these antinutrients (celiacs are an exception), larger amounts of raw foods regularly in the diet may pose problems for proper digestion of some important nutrients.  In many cases fermentation, cooking, soaking and malting can reduce the effect of these anti-nutrients.

Have a hard look at your diet.  If you habitually eat large amounts of unprocessed nuts, seeds, grains or some vegetables, you may be contributing to a chronic malabsorption of an essential metabolite, often a mineral such as iodine, zinc, potassium, calcium, iron, or magnesium.  And the consequence of that may be many health problems, some of which are hard to diagnose:  frequent illness, generalized fatigue, weakness, osteoporosis, arrhythmia, goiter, maldigestive symptoms, and the like.

Dietary interventions for acne

Acne is a Western disease.  You ever see someone living in a non-Westernized country with acne?  Although the association between diet and acne has seemed at best controversial in scientific circles, since 2007 there have been consistent observations that several dietary factors do in fact affect the incidence of acne.

THE QUICK TAKE:  Western diets have high calorie uptake, high glycemic load, high fat and meat intake, as well as increased consumption of insulin- and IGF-1-level elevating dairy proteins, all of which lead to hormonal changes that can cause acne.    In a large study done in South Korea, intake of instant noodles, junk food, carbonated drinks, snacks, processed cheeses, pork, chicken, nuts and seaweed were significantly higher in acne patients than in the controls. Conversely, the frequency of vegetables and fish intake was significantly higher in the control group than in the acne group. The best diets to cure acne?  Any with lots of fruits and vegetables, and no dairy products:  A vegan or paleolithic diet.


Dietary intervention in acne:  Attenuation of increased mTORC1 signaling promoted by Western diet.  Bodo Melnik.  Dermatoendocrinol. 2012 January 1; 4(1): 20–32. doi:  10.4161/derm.19828  PMCID: PMC3408989

The influence of dietary patterns on acne vulgaris in Koreans. Jung JY, Yoon MY, Min SU, Hong JS, Choi YS, Suh DH. Eur J Dermatol. 2010 Nov-Dec;20(6):768-72. doi: 10.1684/ejd.2010.1053. Epub 2010 Sep 7.

Acne vulgaris: a disease of Western civilization. Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Arch Dermatol. 2002 Dec;138(12):1584-90.

Diet and acne: a review of the evidence. (or full article here) Spencer EH, Ferdowsian HR, Barnard ND. Int J Dermatol. 2009 Apr;48(4):339-47. doi: 10.1111/j.1365-4632.2009.04002.x.

Dietary Cholesterol: Still a risk factor for CHD?

THE QUICK TAKE:  Contrary to long-standing perceptions, dietary cholesterol, whether from egg consumption, shellfish, or other foods of animal origin, does not have any adverse effect on serum lipids or risk of coronary vascular disease or stroke.  Recent studies have in fact shown positive effects on HDL cholesterol (which is why an elevated total cholesterol is now thought to be misleading), LDL/HDL ratio, and LDL and HDL particle size (which is associated with less atherogenic lipid particles), and lower risk of hemorrhagic stroke.  There no longer appears to be a need for an upper daily limit for dietary cholesterol consumption;  eggs are increasingly being viewed as health food.

THE ONE MINUTE VERSION: Although proponents of the Lipid Hypothesis have long promoted dietary cholesterol as a risk factor for elevated serum cholesterol and therefore also for increased coronary disease risk, recent researchers1 2 have called into question to rethink  this association.  Although the USA continues to put an upper daily limit of 300mg for dietary cholesterol, European countries, Australia, Canada, New Zealand, Korea and India have removed this restriction.  And, given the otherwise dense nutritional value of eggs, (widely thought of as the highest concentration of cholesterol in the Western diet), there seems to be pressure to reassess the decades-long vilification of dietary cholesterol.

Much recent research has supported this perspective.  A large prospective study reported that increased shellfish intake (another high source of dietary cholesterol) was associated with a significantly decreased risk of myocardial infarction in middle-aged men. The Tehran Lipid and Glucose Study found no relation of dietary cholesterol to serum LDL cholesterol, although it was positively correlated with HDL cholesterol levels.   Another study found that cholesterol-rich foods were associated with a decrease in plasma LDL cholesterol during a calorie restricted diet. And after following more than 20,000 men for 20 years, the Physician’s Health Study did not find any association with increasing egg consumption and myocardial infarction or stroke. And finally, a 2013 meta-analysis of prospective cohort studies reported  “no evidence of a curve linear association was seen between egg consumption and risk of coronary heart disease or stroke”, and in fact, “people with higher egg consumption had a 25% lower risk of developing hemorrhagic stroke.”

Some of the pre-eminent researchers in the diet-heart health hypothesis have subsequently refuted some of their previously held convictions.  Ancel Keys, the author of the Seven Countries Study, felt by many to be the father of the lipid hypothesis, “notes the often inaccurate publicity concerning the importance of dietary cholesterol”, as quoted in a letter to the editor of the New England Journal of Medicine:

Dietary cholesterol has an important effect on the cholesterol level in the blood of chickens and rabbits, but many controlled experiments have shown that dietary cholesterol has a limited effect in humans.  Adding cholesterol to a cholesterol-free diet raises the blood level in humans, but when added to an unrestricted diet it has a minimal effect.  …..(Instead), emphasis on the fatty acids in the diet is needed.” (Source: Ancel Keys:  “Letter: Normal Plasma Cholesterol in a Man Who Eats 25 Eggs aDay,”  New England Journal of Medicine, Aug 22, 1991; 325(8): 584.)

And this from George V. Mann, MD,  Associate Director of the Framingham Heart Study:

The diet‐heart idea [the notion that saturated fats and cholesterol cause heart disease] is the greatest scientific deception of our times. This idea has been repeatedly shown to be wrong, and yet, for complicated reasons of pride, profit and prejudice, the hypothesis continues to be exploited by scientists, fund‐raising enterprises,food companies and even governmental agencies. The public is being deceived by the greatest health scam of the century.

(Mann,George V., “Coronary heart disease – ‘Doing the wrong things.’”  Nutrition Today, Jul/Aug1985; 12‐14.)

And finally this quote from the longest standing director (1979-2005) of the Framingham Study, William Castelli, MD:

“….in Framingham, Mass, the more saturated fat one ate, the more cholesterol one ate, the more calories one ate, the lower the person’s serum cholesterol. The opposite of what one saw in the 26 metabolic ward studies, the opposite of what the equations provided by Hegsted et al and Keys et al.”

(Castelli, William, “Concerning the Possibility of a Nut. . .”  Archives of Internal Medicine, Jul 1992; 152(7):1371‐1372.)

So what can we say about and risk of dietary cholesterol with CVD?  In short, there appear to be no adverse effects of dietary cholesterol on lipid levels, but rather, there appear to be positive effects on HDL, LDL/HDL ratio, and LDL and HDL particle size. The introduction of this review summarizes it well:

“Dietary cholesterol has been shown to increase both LDL and HDL in those individuals who respond to a cholesterol challenge without altering the LDL cholesterol/HDL cholesterol ratio, a key marker of CVD risk. Further, dietary cholesterol has been shown to increase only HDL with no changes in LDL with average cholesterol consumption and during weight loss interventions. Ingestion of cholesterol has also been shown to increase the size of both LDL and HDL particles with the associated implications of a less atherogenic LDL particle as well as more functional HDL in reverse cholesterol transport. Other changes observed in lipoprotein metabolism are a greater number of large LDL and decreases in small LDL subfractions.”



Rethinking dietary cholesterol. Curr Opin Clin Nutr Metab Care. 2012 Mar;15(2):117-21. doi: 10.1097/MCO.0b013e32834d2259. Fernandez ML.

Exploring the factors that affect blood cholesterol and heart disease risk: is dietary cholesterol as bad for you as history leads us to believe? Kanter MM, Kris-Etherton PM, Fernandez ML, Vickers KC, Katz DL.  Adv Nutr. 2012 Sep 1;3(5):711-7. doi: 10.3945/an.111.001321.

Fish and Shellfish Consumption in Relation to Death from Myocardial Infarction among Men in Shanghai, ChinaJian-Min Yuan, Ronald K. Ross, Yu-Tang Gao and Mimi C. Yu. American Journal of Epidemiology Volume 154, Issue 9  Pp. 809-816.

Combined effects of saturated fat and cholesterol intakes on serum lipids: Tehran Lipid and Glucose Study.  Mirmiran P, Ramezankhani A, Azizi F. Nutrition. 2009 May;25(5):526-31. doi: 10.1016/j.nut.2008.11.018. Epub 2009 Jan 3.

Increased dietary cholesterol does not increase plasma low density lipoprotein when accompanied by an energy-restricted diet and weight loss. Harman NL, Leeds AR, Griffin BA.  Eur J Nutr. 2008 Sep;47(6):287-93. doi: 10.1007/s00394-008-0730-y. Epub 2008 Aug 26.

Egg consumption in relation to cardiovascular disease and mortality: the Physicians’ Health Study.  Luc Djoussé and J Michael GazianoAm J Clin Nutr April 2008vol. 87 no. 4 964-969.

Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies. Ying Rong, Li Chen, Tingting Zhu, Yadong Song, Miao Yu,  Zhilei Shan,  Amanda Sands, Frank B Hu, Liegang Liu. BMJ 2013; 346 doi: (Published 7 January 2013)

“Letter: Normal Plasma Cholesterol in a Man Who Eats 25 Eggs aDay,”  Ancel Keys. New England Journal of Medicine, Aug 22, 1991; 325(8): 584.
Dietary Cholesterol Affects Plasma Lipid Levels, the Intravascular Processing of Lipoproteins and Reverse Cholesterol Transport without Increasing the Risk for Heart Disease. Jacqueline Barona and Maria Luz Fernandez. Nutrients. 2012 August; 4(8): 1015–1025. Published online 2012 August 17. doi:  10.3390/nu4081015

On supplements…

THE QUICK TAKE:  Unless you have a demonstrated deficiency, or a high degree of suspicion for a deficiency, there is little evidence of benefit for the regular use of supplements for otherwise healthy people, and surprisingly, there has been some evidence of harm.  Nutrients best come from whole food, and in their original form, given that what the human body is best adapted to absorb.  Save your money, and spend it on healthy whole foods instead, especially locally grown and organic when possible.


Although this is an estimated 25-billion dollar per year industry in the USA alone, the evidence for the use of supplements for otherwise healthy people, the “worried well”, remains murky, and recent reviews have not helped to clarify the value of taking them.  Even calcium, for decades one of the most recommended supplements for women, despite only minimal demonstration of benefit for some post menopausal fractures in an older cohort study in 1997 and 2002, has more recently been reported as having no benefit in one review, and possible increased risk of fractures was reported in a meta-analysis of prospective cohort studies and randomized control trials. And now a 12 year prospective study published in 2013 in JAMA has linked supplemental (but not dietary) calcium intake with increased risk of cardiovascular disease.  For a comprehensive review on the health effects of calcium, in food and in supplements, see this recent report by the National Institutes of Health, Office of Dietary Supplements.

There are many beliefs that people hold that seem to justify the use of various supplements, yet the science is lagging behind.  Check out a recent post by food author, nutrition expert and blogger Marion Nestle, who recognizes a difference in what has been scientifically demonstrated versus what people believe is true.

The perceived need for supplements has lead to their use as an insurance policy for complete nutrition, for several reasons:

  • Many people’s diets do not always follow dietary recommendations–since avoidance of fruits and/or vegetables is common, eating habits may lack many essential nutrients.
  • Foods grown on depleted soils may lack essential nutrients, an uncertainty worsened by our increasing ignorance of where foods originate. The trend of buying organic foods and buying locally are reflections of this concern.
  • Pollution, pesticides, smoking, illness, high work or exercise loads, and stressful living conditions may increase nutrient requirements, and particularly, anti-oxidative needs.
  • Cooking and various other forms of food processing decreases or destroys essential nutrients; conversely, some cooking techniques may add nutrients, such as iron from cookware, or toxins from high heat exposures.
  • Nutrient-related physiological functions and nutrient absorption decline with age.
  • Many patients with poor health or fatigue most often assume they are lacking a nutrient (although there are many possible causes), and therefore pursue supplementation to improve their condition.

A science-based approach considers:

  • Food in reasonable variety is sufficient to meet nutrient needs.
  • Foods provide a wide variety of nutrients that work in synergy (and in better physiological balance) and other valuable substances (such as phytochemicals) not present in supplements.  Humans are best adapted to consuming whole foods, and recognized naturally occurring nutrients.
  • The concentrated nature of supplements may adversely affect absorption of other competing nutrients and the balance of healthy bacterial flora.  They also do not usually come with necessary enzymes, buffers, and synergistic cofactors, as with natural food.
  • People who take supplements are better educated, more physically active, and wealthier: they are healthier whether or not they take supplements, which confounds the perception that taking supplements make people healthier.
  • Studies to date have failed to demonstrate the value of a wide variety of supplements for otherwise healthy people, and some have found increased risks.

Marion Nestle has had several comments on the pros and cons of supplements in recent years, on vitamin, calcium and osteoporosis here, the claims of the supplement industry here, on the minimal health benefits for cancer here, and more bad news on supplements here.

Consider the Iowa Women’s Health study, which associates increased mortality with several supplements, especially iron.  Or a long term followup of the SELECT trial, that confirmed that there was a significantly increased risk of prostate cancer with Vitamin E supplementation.  A 2009 review of vitamin supplementation and risk of various cancers is overall disappointing.  A 2007 meta-analysis in JAMA suggested that some supplements, such as vitamin A, E, and beta-carotene, posed increased risks. Yet an older observational study on vitamin A and osteoporosis suggested that both low and high serum levels posed a risk of hip fracture.

Most recently, The USPSTF concluded that “the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women or in men.”   See Figure.

Yet, there are reviews that appear to justify increasing risks of various nutrient deficiencies.  Vitamin C intakes may be inadequate in those who avoid fruits and vegetables, who smoke, or who are ill, as outlined by this review.  There is evidence that low vitamin K intakes associate with increasing risk of osteoporotic fractures, and supplementation strongly associates with a decreased risk. Increased vitamin K2 has also been associated with decreased risk of coronary calcification in post-menopausal women in this observational study.

So, despite many years of supplementation by millions of people, the evidence for any value of supplementation remains limited, weak or contradictory, and in some cases suggest increased risk.  Consider the statements in the introduction to a 2009 review on the concept “food synergy”:

“…. ‘‘thinking food first’’ results in more effective nutrition research and policy. The concept of food synergy provides the necessary theoretical underpinning. The evidence for health benefit appears stronger when put together in a synergistic dietary pattern than for individual foods or food constituents.  A review of dietary supplementation suggests that although supplements may be beneficial in states of insufficiency, the safe middle ground for consumption likely is food. Also, food provides a buffer during absorption. Constituents delivered by foods taken directly from their biological environment may have different effects from those formulated through technologic processing, but either way health benefits are likely to be determined by the total diet. The concept of food synergy is based on the proposition that the interrelations between constituents in foods are significant.”

“A person or animal eating a diet consisting solely of purified nutrients in their Dietary Reference Intake amounts, without benefit of the coordination inherent in food, may not thrive and probably would not have optimal health. This review argues for the primacy of food over supplements in meeting nutritional requirements of the population”.

So, unless you have a demonstrated deficiency of a specific vitamin or mineral, or a reasoned possibility of deficiency, save the money you spend on supplements, and redirect to a variety of healthy, whole foods purchases.  And if you do need a supplement, the most commonly justified are iron, vitamin B12, vitamin D, omega-3 fatty acids, vitamin K2, and magnesium.  Just make sure that you are getting them in the form that is a close to biological as possible.  For example, folate does not appear in nature, but tetrahydrofolate does.  For another review  on wise supplementation, go here.  And there is a healthier way to get stronger bones: exercise!  Check out what the National Osteoporosis Foundation recommends here.




Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trialsHeike A Bischoff-Ferrari, Bess Dawson-Hughes, John A Baron, Peter Burckhardt, Ruifeng Li, Donna Spiegelman, Bonny Specker, John E Orav, John B Wong, Hannes B Staehelin, Eilis O’Reilly,Douglas P Kiel, and Walter C Willett. Am J Clin Nutr  December 2007 vol. 86 no. 6 pp.1780-1790.

Calcium Intakes and Femoral and Lumbar Bone Density of Elderly U.S. Men and Women: National Health and Nutrition Examination Survey 2005–2006 Analysis. J. J. B. Anderson, K. J. Roggenkamp and C. M. Suchindran. J Clin Endocrinol Metab. 2012 Dec;97(12):4531-9. doi: 10.1210/jc.2012-1407. Epub 2012 Oct 15.   See also this.

Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition studyHeart. 2012 Jun;98(12):920-5. doi: 10.1136/heartjnl-2011-301345.

Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis.   BMJ. 2010 Jul 29;341:c3691. doi: 10.1136/bmj.c3691. Bolland MJAvenell ABaron JAGrey AMacLennan GSGamble GDReid IR.

Dietary and Supplemental Calcium Intake and Cardiovascular Disease MortalityThe National Institutes of Health–AARP Diet and Health StudyQian Xiao, PhD; Rachel A. Murphy, PhD; Denise K. Houston, PhD; Tamara B. Harris, MD; Wong-Ho Chow, PhD; Yikyung Park, ScD  JAMA Intern Med. 2013 Feb 4:1-8. doi: 10.1001/jamainternmed.2013.3283.

Calcium supplements: bad for the heart? Ian R Reid,  Mark J Bolland. Heart. 2012 Jun;98(12):895-6. doi: 10.1136/heartjnl-2012-301904.

Diet Supplement Fact Sheet: Calcium.  Office of Dietary Supplements, National Institutes of Health, USA Office of Disease Prevention.  Reviewed: March 14, 2013

The risk of kidney stone formation: the form of calcium matters. Favus MJ.  Am J Clin Nutr. 2011 Jul;94(1):5-6. doi: 10.3945/ajcn.111.018481. Epub 2011 Jun 1.

Long term calcium intake and rates of all cause and cardiovascular mortality: community based prospectivelongitudinal cohort study. Michaëlsson K, Melhus H, Warensjö Lemming E, Wolk A, Byberg L. BMJ. 2013 Feb 12;346:f228. doi: 10.1136/bmj.f228.

Dietary and Supplemental Calcium Intake and Cardiovascular Disease Mortality: The National Institutes of Health-AARP Diet and Health Study. Xiao Q, Murphy RA, Houston DK, Harris TB, Chow WH, Park Y. JAMA Intern Med. 2013 Feb 4:1-8. doi: 10.1001/jamainternmed.2013.3283.  See also this.

Effects of widely used drugs on micronutrients: A story rarely told. Samaras D, Samaras N, Lang PO, Genton L, Frangos E, Pichard C.  Nutrition. 2013 Apr;29(4):605-10. doi: 10.1016/j.nut.2012.11.011.

Calcium intake and fracture risk: results from the study of osteoporotic fractures. Cumming RG, Cummings SR, Nevitt MC, Scott J, Ensrud KE, Vogt TM, Fox K. Am J Epidemiol. 1997 May 15;145(10):926-34.

Meta-analyses of therapies for postmenopausal osteoporosis. VII. Meta-analysis of calcium supplementation for the prevention of postmenopausal osteoporosis.  Shea B, Wells G, Cranney A, Zytaruk N, Robinson V, Griffith L, Ortiz Z, Peterson J, Adachi J, Tugwell P, Guyatt G; Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group.  Endocr Rev. 2002 Aug;23(4):552-9.

Diet: Key Messages


1) What you eat can also impact on a host of significant diseases.  This is the same list as exercise, and more: allergies, asthma, skin problems, acne, macular degeneration, chronic fatigue, IBS, frequent illness, gout, kidney stones, gall bladder disease, appendicitis, muscle and joint soreness, and more.  Your diet also impacts most important biomarkers of disease.

2) There is no one diet that solves everyone’s problems.   We are are unique and special snowflakes. People have done well (and probably poorly) on virtually every published diet, from Atkins to Ornish to Mediterranean to vegan/vegetarian to  Zone diets.  You may need to follow a variety of dietary principles, or need to try different diets that your doctor might suggest to you.  Popular diets in the press that you may have read about can be assessed and supervised by your doctor.

3) For a wide variety of symptoms consider a dietary element.   If you have ongoing gastrointestinal complaints, such as Irritable Bowel Syndrome, or recurring migraines, joint aches, fatigue, iron deficiency, skin problems, even asthma, there may be a dietary link.  Some foods that are thought to be healthy for most, cannot be tolerated by others. Many populations cannot digest the lactose in dairy products, several components in wheat, or the raffinose or stacchyose in beans.  Don’t be afraid to do some experiments, and talk to your doctor about what might work.  Even consider a brief fast to test your theory out.  Unfortunately, there are not easy tests for most of these problems, as they are not a true “allergy” in most cases.

4) Whole foods are generally better choices than processed foods. The more a food has been processed, the more nutrient depleted the food is, and the more likely it has had various additives included that are unlikely to have been tested for long term safety.  Whole foods may cost more, but you get more as well, and especially in an integrated, natural form that your body is probably better conditioned to digest and absorb. The more the cells of the food have been preserved, the more “whole” and unprocessed it is.  Processed foods often increase the risk of overeating as well, as they are digested too quickly, and may cause hypoglycemia.  There is probably no such thing as a healthy baked good.

5) Avoid trans fats.  These are artificially created fats that do not occur in nature, and are strongly associated with pro-inflammatory effects on blood vessels and therefore increases risk of heart disease.  These occur in margarines and alot of refined food products.

6) Don’t avoid all fats.  Although low-fat diets have been promoted for decades, it is now known that several kinds of fats are health-promoting, if not vital to healthy function.  This includes especially omega-3 fatty acids, which are best found in cold water fishes, such as salmon, mackerel, sardines and herring.  Although mono- and polyunsaturated fats are considered healthful, some are unstable with cooking, and refined oils are, well, refined.  Humans have not eaten processed oils through most of human history.

7) Avoid any foods that contain refined starches or refined sugars, including high-fructose corn syrup.  Sugar consumption 100 years ago was only about 5-10 lbs per person per year in North America, but it has zoomed up to an estimated 150 lbs per person per year by 2010.  There is no precedent for this.  We are eating more white flours products that ever before, in part due to the low fat movement and the desire for cheap and convenient food.  This change associates strongly with increasing rates of obesity and diabetes, which have at their core impaired carbohydrate intolerance.  Sugars and refined starchy carbohydrates are known to be pro-inflammatory, and adversely affect both cholesterol and triglyceride levels, which in turn, increases heart disease risk.

8) Be aware that some foods contain anti-nutrients that interfere with absorption of some minerals.  Calcium, iron, magnesium and zinc are all vital minerals that share a common pathway of absorption, that can be precipitated by phytates (common in the hulls of nuts, seeds and grains); they are also chelated by several  flavonoids, which reduce absorption and and also inhibit digestive enzymes. One mineral supplement can interfere with absorption of another mineral in the diet. Trypsin inhibitors and lectins (found in legumes) also interfere with digestion.

9) Eat a variety of fresh fruits and vegetables every day.  In whole form, these foods are the closest to what our species have eaten for most of our existence, and are therefore most likely to contain the nutrients we need to survive.  Hundreds of studies done over the last several decades have repeatedly demonstrated the healthfulness of eating these foods, which are excellent sources of a multitude of micronutrients.  The exception is white potatoes, which have been associated with adverse health effects due to its high glycemic index.

10) Don’t drink your fruit.  Dietary refined sugars have been increasingly linked to chronic disease and inflammatory changes, and this includes fructose.  There is as much sugar in a can of pop as there is in a glass of juice, and liquid calories do not provide satiety, leading to overeating.  Whole fruit comes with many other nutrients and fiber, and is a natural source of water.

11) Healthful diets can include meat, shellfish and fish, especially if they are minimally processed.    Grass-fed and wild meats are generally better than grain-fed.  Wild fish is usually better than farmed, although there are some exceptions.

12) Nuts and seeds in moderation are generally healthful if unprocessed.   These are high in protein, vitamins and fiber when unprocessed, and can be useful to curb appetite in small amounts. Unfortunately,some nuts are also strongly associated with allergic reactions, and some contain some anti-nutrients that may interfere with absorption of other nutrients.

13) If you follow the above principles dietary supplements are usually unnecessary.   Getting your nutrients from whole foods over vitamin and mineral supplements is a more reliable, cheaper and more complete way to get all of your nutrient needs.  Science, by its nature is reductionist, causing us all to look at one nutrient at a time, yet our bodies use nutrients in a complex and orchestrated way that is profoundly dissimilar from taking concentrated nutrients in isolation.

14)  If you are reading labels, you are already in trouble.  Labels imply that this is a processed food, and health claims most often imply a food depleted of nutrients. Yet there are only a handful of foods on supermarket shelves that contain 4 or less ingredients that are recognized as food.  Author Michael Pollan (In Defense of Food, 2008) calls these products “food-like substances.” If you don’t recognize the ingredients, don’t buy food chemistry, as it is not associated with health.

15) Learn how to prepare 10 easy to make, inexpensive, healthful meals that can save your life (and/or your family’s lives).   Our current generation of young people have grown up with a warped perspective on food–they don’t know where it comes from, they don’t know how to cook, they see a major source of food as packaged convenience foods or fast-food restaurants.  Most of what they think are every-day foods didn’t exist even 50-100 years ago!

16) Embrace eating as your ancestors did by preparing whole foods, and growing your own.  Too many of us fuel our bodies in our cars and give no time or thought to what we put in it.  Treat your body like a temple—it is the only one you will ever get.  What you put in your tank matters!


The most useless words on a food label…

Ever wonder what “natural”, “lean”, “made with…”, “lite”, or some other terms on a food label mean?  As it turns out, not very much.

Check out this summary, and get cynical the next time you walk down the grocery store aisles.

Diet as Medicine

screenshotDespite the strong and likely justified belief that dietary changes can significantly alter a wide variety of disease risks, the topic remains contentious, with thousands of popular diets (check some out here) published, all proporting to improve health in some way.  These all have varying degrees of science behind them, although it takes considerable sleuthing to sort out what are observational studies that only imply cause and effect simply by association.  And, as it happens, nutritional research is hard to do because of the unreliability of food questionnaires, the costs of metabolic lab studies, and the difficulty of holding one variable constant while others are not in fact inversely affected.  It is often very hard to tease out the important element(s) within a diet that may be the linchpin in a given disease.

Traditional and modern diets vary considerably; high fat, low fat, medium fat, high carb, low carb, high animal food, high plant food. And they come with a multitude of confounders:  Seventh Day Adventists are often held up as having a healthy diet, yet their lower mortality rates may also be associated with lower incidences of smoking, alcohol consumption, better sleep, healthier exercise patterns, and a strong supportive community.  Many diets seem to offer benefits due to their high fruits and veggies content, but these diets may also have less refined foods such as refined oils and sugars as well.  Further, it appears that higher fat, salt and protein intakes have been a proxy for a country’s development, with inherent differences in fast food availability, access to refined foods, activity, stress, pollution, medical support, poor sleep, and loneliness– all possible confounders.

screenshotAnd what of the difficulty to accurately tabulate death rates of given diseases in underserviced and rural areas, especially when some countries report sudden death as a distinct entity?  Is the “French Paradox” just a statistical anomaly?  How do we explain the fat intakes of the traditional Innuit, who eat virtually no plant-based foods? And how do we reconcile significantly different food guidance systems in different countries, especially when these documents are created with stakeholders in place, namely the food industry, as occurs in Canada—are we not all the same, or are these politicized documents? And how is it that the understanding of, and the approach to, the epidemic of obesity seems to be so limited as to be ineffectual?  One would think, with the strong association with multiple other diseases, such an “epidemic” would stimulate an urgent response from a wide variety of sources, yet there is almost nothing.  How bad does it have to get? Confusion reigns in the marketplace.

Nevertheless, we plod on.  Despite the seeming hopelessness of this exercise, trends and common themes appear, although we are often forced to make sufficient conclusions from insufficient premises. Given the best seller lists, patients have done well on a wide variety of diets, so it may be that we are all special snowflakes, and one size does not fit all.  The n = 1.

What follows is a summary of various diets, the main principles and evidence behind them. So for the busy clinician who does not have the time to read these latest books, we can provide you with a one minute snapshot of what the diet proports to do, with more links to more references.  As well, a number of daily blogspots will be offered as well that are easily subscribed to if interested.  We hope to also be able to help you develop clinical strategies to help your patients improve their diets, and how to monitor the process.