My 5 Days on the Fasting Mimicking Diet

fasting.PNG

So, I don’t know why I didn’t share my experience with the FMD in real time on my Instagram stories, but I guess I’ll share a little bit of my hesitation before I get into sharing my experience.

As some of you know, I, like many (all?) nutritionists, haven’t always had the healthiest relationship with food (hello 5’9’’ 119 lbs). When I was at my worst, I would always claim that I had “never followed a diet in my life” and “I ate whatever I wanted.” Ok, well when you’re obsessively thinking about every single bite you take throughout the day and mentally calculating your caloric intake, you may not be “on” South Beach or Weight Watchers or Atkins, but you’re not living your best life.  

I’ll spare you the journey between healing my relationship with food (if you’re curious, you can read about it here), but I was always hesitant with fasting (and keto) from the start.

I remember about 5 or 6 years ago when my old boss and my nutritionist colleague (we were working in an integrative medicine clinic in an academic med center) started discussing keto and the evidence for certain cancer populations (brain cancer, at that point). Also, there was emerging evidence about fasting for cancer patients before chemo treatments, and that fasting seemed to be helpful for side effects of chemotherapy (less nausea, etc… which I guess makes sense because you don’t have anything in your gut).  

Aanyway, knowing that any kind of diet and restrictive eating could be a trigger for disordered eating for me, I hesitated.

So, although I like to think of myself as an early adopter, based on my personal experience (and knowing the risk of a trigger), I decided to read/learn more about it… After reading, listening and watching (documentary Amazon Prime called “The Science of Fasting” where they interview Dr. Valter Longo PhD) more about FMD, I thought about using it with a few clients I’ve worked with over the years. It seemed like it might be a great fit for their needs and their cardiometabolic (cardiovascular + prediabetic/inflammatory-type metabolic pattern) issues. I also had heard from some colleagues that they were having great experiences with the program.

But, before I put a client through the program, I needed to try it myself.

So, the week before Thanksgiving, I decided to do the 5-day “fast,” which isn’t actually a fast, and that’s why they call it the “fasting mimicking diet.”

You get the benefits of fasting (turning on anti-inflammatory activity in the body, essentially turning on your body’s clean up crew and anti-aging gene activity) without actually having to fast.

Hooray!

Maybe it was after I started noticing forehead lines that weren’t going away when I unfurrowed my brow or (gasp) my first gray hair… And, ok so I barely wash my face outside of the shower and only recently started using oil at night to prevent wrinkles. So, I’m not gonna pretend like I am excited for this whole aging thing…

Alright, I’ll spare any additional rambling and share how it went for me:

Days 1-3:  

The food/drink: It’s prepackaged food, but for prepackaged food, it’s good prepackaged. For breakfast you always eat a nut/granola-type bar. It’s good (but small).  They always give you tea to drink, and I didn’t read the instructions well enough to know whether I was supposed to drink coffee, so… of course I did.

Lunch and dinners are always soups and sometimes olives and/or flax crackers. Then, at the end of a couple days you get some kind of weird chocolate thing with inulin in it, which I called the “fart bar.” The inulin is a “prebiotic” (fiber), which serves, functionally, to keep the digestive tract moving along, but bloated me something fierce.  

Sorry, Rob.

On days 2-5 they have you start drinking a proprietary electrolyte/glycerol concentrate that’s added to water. I put mine in the bottle they gave me and added the 2 tea bags of hibiscus tea to steep most of the day. I don’t fully understand what’s in the drink, but it was nice to sip on between meals.  

Supplements: They give you an omega 3 (algae (not fish) source) and some kind of multivitamin that I wouldn’t have designed that way, but it was 5 days. They were fine, and I took them no problem.

Energy/hunger: To ruin any anticipation or build up, I honestly felt great, especially days 1-4.

I couldn’t believe how well I transitioned into the “fast” (and maybe it’s because I’d done a short stint of a fast/shortened my eating window earlier this year), but I didn’t have any blood sugar “crashes” or “hangry” moments. However, Rob (my husband) might disagree (read on)…

Mindset/Food obsession: I was really busy on days 1 and 2. I saw clients all day each day and had some evening activities, so I didn’t have much time to think about it. I really liked that aspect (keeping myself busy felt key).

By end of day 2 and into day 3, Rob will tell you that I got more preoccupied with food. I was admiring his bowl of ice cream after dinner and even pining over the regular meals he was eating.

Oh, one other random thing: I had some really vivid dreams and slept very deeply for the first 3 nights.

Days 4-5:

The food/drink/supplements: Same bars, soup, crackers/olives. Some of these meals are even more sparse (just soup), and I would eat like 1/8 teaspoon at a time to draw out the meal longer than 90 seconds. Again, I really honestly enjoyed the food. Perhaps I was hungry enough?!

Hunger: I was talking and obsessing about food/eating. It was actually extremely interesting as I reflect back because I hadn’t been that obsessed with food since I was deep in my disordered eating. Rob would tell you that I was talking a lot about food and fast a lot of the time.  

After day 4 I was ready to quit and had been texting with my friend and colleague Amy about it (she’d done it a few times and had a good experience). I told her, “I think I’m good” and would maybe be finish a day early. She text-yelled at me (coached me) to keep going. She reminded me that the program was designed to mimic fasting and was an evidence-based approach to facilitate autophagy (basically the body cleaning up dead cells). So, thanks to Amy, I made it through day 5.

Energy/temperature: The final (5th) day I remember wearing an extra layer of clothes (it’s also been a cold late fall in Kansas City) and took the dog on an abbreviated walk because I was cold and didn’t have the energy to do our typical 3 mile route.

I was hungry.

Day 6 “Refeeding” Day: They tell you to start by drinking liquids (brothy soups, juices, etc.), so I had some apples that I blended in with some water and strained (too lazy to go to the grocery store, ok?!), and that honestly went really well. I tried some sweet potato and venison chili that Rob had made a couple days before for lunch, and had a teeny bit of gurgling in my stomach, which was likely just waking up after the several days. That evening I ate at my parent’s house (the night before Thanksgiving) and had some scallops and steamed broccoli (and maybe a glass of wine – hello right to my head).

This day went extremely smoothly, and I was pleasantly surprised that my body adapted back to food so smoothly. I think one key is taking the morning slowly and not eating any large amounts of foods or anything out of your typical norm of eating.

Thanksgiving: We didn’t have a normal thanksgiving meal on this day, but we did eat well. I felt just fine, and transitioned fully back to eating. As a general rule, I avoid (with my mom, brother and Rob) gluten, so that wasn’t hard because that’s built into our family.

Overall Reflections: To be honest, I would probably do it again. It’s 5 days, it’s laid out of me (exactly what I had to eat and clear instructions). My only hesitation and caution I would give is to make sure you are mentally/emotionally fit for taking on something like this. It can easily trigger obsessive thoughts about food, disordered eating and could feed into further yo-yo dieting (if that’s something you’ve historically done).

The evidence for fasting (to me) is fascinating. I love the idea that it turns on anti-aging genes and allows our body to “clean itself up.” I also love the idea that throughout history, many cultures and religions have fasting built into their lives. Ancient wisdom is fascinating.

So, what else do you want to know? Comment below!

Ketogenic Diet: Interview with a Keto Expert

 The ketogenic diet ("keto") has gained significant popularity. I sat down with my friend and colleague, Dr. Matt Taylor, to get his take on FAQs of keto (including his research on the ketogenic diet among patients with early stage alzheimer's disease!).

The ketogenic diet ("keto") has gained significant popularity. I sat down with my friend and colleague, Dr. Matt Taylor, to get his take on FAQs of keto (including his research on the ketogenic diet among patients with early stage alzheimer's disease!).

I know I already wrote a blog post about why the ketogenic diet (keto) seems to be everywhere right now, but this article is going to give you tons more information from a ketogenic expert (Dr. Matthew Taylor has studied the ketogenic diet in people with Alzheimer’s disease). To catch you up on the basics of what’s going on with keto: the ketogenic diet is popular because a lot of people are finding it helpful for weight loss. In reality, it’s a new version of the Atkin’s diet, or at least the Atkin’s approach is based on the idea that our bodies will shift into burning fat when we deprive it of high amounts of carbohydrates. It’s an adaptive response our bodies have when we are faced with famine. It’s normal, natural, and generally safe… with a few asterisks, of course.

There was quite a bit of buzz around my blog post, so I wanted to follow up with some additional, in-depth background on the therapeutic use of the ketogenic diet.

So, I interviewed one of my former classmates and friend, Dr. Matt Taylor, who is a ketogenic diet expert and studied the diets (and did a keto diet intervention) among patients with Alzheimer’s disease (I’ll refer to as AD). His research used the ketogenic diet to see if it would improve cognitive symptom changes in patients with AD, and/or result in any measurable cognitive outcomes. Spoiler alert! Even though his study population was only 11 people, 10 of them had measurable improvements in their cognitive symptoms. That’s unheard of in comparison to AD medications. Typically AD meds will help with slowing the decline, but none of them actually result in improvement. Well, participants in Dr. Taylor’s study had actual improvement.

He's published a couple papers on the topic: the first found that a high glycemic (refined carbohydrate/likely processed food) diet was associated with higher burden of alzheimer's disease markers and the second study showed that putting people with mild (early) AD on a ketogenic diet was feasible

I sat down with Dr. Taylor a few weeks ago and picked his brain about many of the questions you have about the ketogenic diet, both related to cognitive health and AD, but I also asked him about who should and shouldn’t follow the diet.

Before I dive into the interview, a little background on the ketogenic diet. The keto diet is a very high fat (80-85% of calories), very low carb (5-10%), and moderate protein (~15%) diet. The idea behind it is that the body can shift, from burning primarily carbohydrates, into burning fat into what are called “ketones” or “ketone bodies.” Thus, the “ketogenic” diet.

Historically, the ketogenic diet has been used for epilepsy in kids when medications don’t work for them. Over time, the diet has been studied in brain cancer, and more recently there has been interest in its use for conditions involving cognition. Dr. Taylor’s study, as I already mentioned, is related to the ketogenic diet’s use in patients with Alzheimer’s Disease.

Here is my interview with Matt, condensed for readability and to avoid redundancy. I also made the more publicly relevant questions at the top and left the more science-heavy (nerdy) stuff at the bottom. Enjoy!

Leigh: So, why is keto so popular right now?

Dr. Taylor: Many researchers, physicians, practitioners, or people involved in the “keto movement” have seen improvement in weight or health conditions by following keto. Then, they encourage others to try it, and it spreads from there.

I think keto is most popular because of weight loss but I’ve also heard from many that follow the diet that they are following it because they believe it is best for their brain health. For weight loss, it’s a diet where you can eat and feel full most of the time – it consists mostly of fat, so it can be very satiating. Sometimes the diet causes people to eat fewer calories and feel satisfied. There is also evidence that some people can eat more calories and still lose weight. From a brain and focus perspective, ketones tend to give a sense of euphoria, so some people just like the way it feels and potentially feel like they have better focus.

Leigh: What are common misconceptions of the ketogenic diet?

Dr. Taylor: The biggest misconception is that this diet is a fix-all approach.

Also, there are many products touted to enhance ketosis, help with symptoms, or help with weight loss. Some of these may or may not actually work. The product consistently shown to be beneficial in this area is MCT (medium chain triglycerides). There is a lot of marketing for beta hydroxybutyrate (BHB) supplements, which research has shown that many don’t actually help raise ketones UNLESS given with MCT oil. With that said, a certain formulation of exogenous ketones has been effective at raising blood ketone levels after administration. I’ve seen posts on social media push products as “you have to be on these supplements follow the ketogenic diet properly” which is not true, some of it is gimmick.

Leigh: So what’s being portrayed in media that IS or ISN’T accurate?

Dr. Taylor: Once again, just the misconception that the keto diet is a panacea. Keeping focused on research, I try to stay away from what media is pushing out, but I do see what’s being marketed on social media. I’ve been asked to talk at conferences and seminars that companies have put on, but I haven’t taken those gigs, so can’t say for certain.

It’s funny, I know several people who research the keto diet that are surprised to learn how many people are following it. Listening to people who are actually DOING it and articulate some of the benefits and obstacles can be helpful for scientific messaging. Sometimes there is good info in the keto communities, but not always.

Side note: here’s my (Leigh’s) previous post about keto that explains more.

Leigh: Who would benefit from following keto?

Dr. Taylor: We use the ketogenic diet very successfully in childhood epilepsy. Evidence has shown potential for people with adulthood epilepsy, Alzheimer’s disease and other neurological conditions, Diabetes, and even Polycystic Ovarian Syndrome (PCOS). There is emerging evidence around people with malignant tumors (specifically Glioblastoma – brain cancer) on keto with a potential shrinking effect and improvement in symptomatology. Individuals who have those types of conditions may benefit from keto. The ketone metabolism research shows us that many of these conditions are metabolic in nature, which we haven’t always known. Where we’re seeing an effect of the ketogenic diet is on conditions driven by metabolic changes impairing our body’s ability to use glucose for fuel. Once that condition has occurred, it doesn’t matter how much sugar you provide, there it seems there is a preference for ketones instead of glucose for fuel. Even in situations when glucose isn’t as usable anymore, such as in Alzheimer’s, ketone metabolism stays intact. Traumatic Brain Injury (TBI) is another condition that I’m researching with the keto diet. 

Leigh: Ok so this sounds like it has potential for a lot of different situations right?

Dr. Taylor: In science, we’re conservative about using approaches that are this extreme because we’re concerned about any possible negative outcomes. It’s interesting, many people have started this diet for many different conditions, and so we’re sort of letting the population do tests on themselves. Healthcare professionals can see the results from an anecdotal standpoint and we can then use this as rationale for future studies.

Leigh: Who shouldn’t follow keto?

Dr. Taylor: First, people with carnitine deficiency should not follow keto (you would have discovered/been diagnosed with this in childhood if this were an issue for you). This deficiency means that it’s harder to get fat into the cell for fuel, and you no longer are providing glucose as fuel either, so this could be a problem. There is some evidence that supplementing with carnitine may be helpful. Really, it comes down to personalizing the diet, because there are different ways to do keto, and it’s not for everyone.

Secondly, people with an APOE4 mutation may want to stay away from keto diet. These people don’t seem as able to handle high amounts of fat, especially saturated fat. This can be tested via genetic testing. It’s suggested that following the keto diet can have adverse cardiovascular effects like increase cholesterol levels and many with the ApoE4 gene don’t seem to have the same cognitive response in research studies.

If you’ve given it a try, consider how you feel. There is an adaptation phase to diet that many people experience, often called “Keto Flu”. The symptoms while adapting vary by individual, I’ve seen people go on the diet and feel great immediately, and other people go a handful of days and feel kind of bad, and others that feel horrible. For many, they adapt and feel good after a few days. Some never adapt at all and never feel good, once again it’s about individualizing the diet for each person. There is some really interesting evidence that feeling this way mostly comes down to low sodium intake to replete the high amount of sodium excreted by following the diet. I recently saw data from a study that put several hundred people on the diet. By ensuring that those individuals consumed plenty of sodium, they were able to attenuate many of the side effects associated with “keto flu.”

Another individual component to consider is insulin level before starting Keto. People with higher insulin levels may take longer to shift into ketosis and possibly feel bad. Also, what is your nutrient status coming in? Many people already lack electrolytes and hydration and this diet requires more hydration. Burning more fat makes you excrete more fluid, so people who aren’t hydrating or replenishing electrolytes will likely feel awful. The diet isn’t for everyone, if you follow this diet and feel awful on it (and continue to feel awful) more personalization may be necessary, or it just may not be right for you.

Side note: people with history of (or current) eating disorder should definitely consult with their healthcare provider and eating disorder recovery/healthcare team before taking on any dietary changes or restrictions.  

Leigh: On a basic level, can we get people to follow keto long term? Should that be the goal? Can we see changes, metabolically, with just macronutrient changes (without focusing on fruits and veggies)?

Dr. Taylor: After the study of metabolic change builds more evidence, then we can ask that more complex questions. We see overall improvement in condition, but what we also want to consider personal experience? I think diet quality could play a part, but that hasn’t been studied yet.

Leigh: What would you tell someone who is thinking about starting keto?

Dr. Taylor: Seek out advice from someone with experience or background in this area, like a Registered Dietitian Nutritionist (RDN). You may run into RDNs who are hesitant to comment or advise on this diet if they don’t have experience with it. However, those with experience would be more apt to provide objective help.

Leigh: What’s one thing you would tell someone to expect?

Dr. Taylor: First, following a ketogenic diet is usually a big change from most people’s typical way of eating. It’s really counterintuitive for many to eat as much fat as is required to follow the ketogenic diet and carbohydrate restriction can be difficult for people who have carbohydrate food cravings. It’s also possible that you may feel crummy for a period of time while your body adjusts to a different type of fuel (shifting from carb-burning to fat-burning).

Leigh: How does one know if they’re just adapting to fat-fueling or that the ketogenic diet isn’t working for him/her?

Dr. Taylor: It could be either, but there are steps you can take in preparation for starting keto that can help you to know if it’s a feasible option before getting fully invested. It could be helpful to know your APOE status, personally I’m a proponent of genetic testing, but I realize that some people are hesitant to that for various reasons. It may be helpful to do blood work from a PCP or other physician who could look at APOE status because we’ve seen people with APOE4 who don’t respond as positively as others. If you don’t know your APOE status and go on this diet, it’s advisable to get your cholesterol checked periodically to make sure you aren’t doing more damage than good.

Another helpful tip is to be proactive with hydration and electrolytes like potassium, phosphorus, and sodium. Bone broth has been helpful for adaptation phase, patients have been using bone broth to feel better and it is becoming more widely available.  In my research, we provided participants a multivitamin and a potassium/phosphorus supplement. My current study in patients with traumatic brain injury (TBI) with a small sample size provides a multivitamin but not phosphorus/vitamin D. I’ve never used exogenous ketone supplements in my research.

Leigh: Is it bad to abrupty start or stop following a ketogenic diet?

No! Actually, with the research we’ve had some interesting findings. The researchers determine “compliance” as following keto about 70-80% of the time. This means that ¼ – ⅓ of the time not following keto, which is a way of cycling, whether it happens intentionally or organically. This indicates cycling or abrupt stopping would be ok. People who have stopped the diet can pick it back up and resume. Once you’ve started making ketones, there’s an idea (among keto experts) that ketone adaptation, where you switch over to ketone fuel metabolism, becomes easier. There isn’t really a concern unless you’re just generally yo-yo’ing (dieting) bouncing back and forth between ketogenic and Standard American Diet (SAD), which is not healthful. This is a lifestyle/behavior change that is so important, and moderation is also important. Extreme shifts may be problematic, but we don’t know because we don’t have the evidence. Variation is important, cycling with a plan is probably a good approach, but we still need evidence on this as well. All these assumptions are also focused on diet quality. If the shift is on keto I eat bacon, eggs, vegetable oil, cheese (not high quality) then shift to bacon, eggs, oil, cheese + carbs, this is a problem no matter what because in both cases the fats are unhealthy.

Another interesting area of research is in athletes and performance. If you wanted to look into it more, Jeff Volek has discussed the concept of cyclic ketosis, which is the idea that if you’re keto-adapted you can be a more efficient athlete because you’re good at using 2 different fuels whenever they’re available.

Leigh:  Are there actual benefits to being in ketosis or burning ketones?

Dr. Taylor: Ketones are not only providing energy but are also powerful messengers that are important for metabolism. A bunch of animal studies have also shown that ketones are anti-inflammatory. Inflammation is necessary for healing an acute injury, but long-term chronic inflammation is linked to chronic disease. So, ketones have been shown to suppress pro-inflammatory pathways over a long period of time.

Leigh: Tell me about your study/work for your dissertation or any of your other keto-related research? Summarize your findings (high level) any surprises? conclusions?

Dr. Taylor: My original exposure to this was a pilot research study with Alzheimer’s disease. One of the key findings in Alzheimer’s patients is that their brains refuse to use glucose as an energy source, so we’ve started to shift our thinking of AD as more of an energy crisis. Amyloid and tau proteins are involved, but it’s more that brain metabolism has changed. Most basic thought behind research was to provide the brain with alternative fuel source. One study he did put Alzheimer’s patients on keto for 3 months, there were 15 participants at the start and 10 of them completed the study. Of those 10, 8 of the patients had improvement in cognition and decreases in Alzheimer’s symptoms. One person worsened, but he had other variables with his health, so it’s difficult to know what was going on, or if it was related to the diet change. With our study, the ketogenic diet education focused a lot on diet quality. Actually, I’m currently writing a paper regarding the positive changes in nutrient density of this study’s ketogenic diet vs. the standard diet that participants were following. I’m convinced that this type of keto diet is very different from a diet that only focuses on macronutrient ratios.

I remember from the research, a story about a patient that would read the newspaper multiple times a day but wouldn’t retain any of that information. About 2 months into the diet/study, the study partner reported that the patient had started reading the paper only once per day and retained some of that information later in the day. This type of story gives me optimism that it might be helpful for Alzheimer’s patients.

Leigh: What surprised you from your studies?

Dr. Taylor:  I was surprised that older adults would follow it! To be honest, it was a challenge because these people have grown up through a low fat marketing era, and people are hesitant to increase fats to the level they needed on the study. Throughout, I had several shifts in perception. I had gone into it thinking it wouldn’t be too big of a challenge, but as I got feedback I realized how ingrained the low fat messaging was for these people. Also, I had no anticipation for the type of cognitive results that we saw. We saw improvements in patients that really compete with, or surpass some of the most successful Alzheimer’s research in the past. In Alzheimer’s research, a drug is considered to be successful if cognition decline is slowed, whereas in this study there was actually cognition improvement.

Leigh: What about the ketogenic diet for non-brain cancers such as Prostate and bladder cancers?

Dr. Taylor: There is some real interest in using it in these conditions, but there is currently not enough research to draw a conclusion. Based on results of other research it wouldn’t surprise me if it might help.

Leigh: Weight loss?

Dr. Taylor: Keto is one of the ways to do it. From experience of putting individuals on the diet, people have been able to eat a higher caloric amount and still lose weight. It has a thermogenic effect in that it boosts fat metabolism, which makes it effective for losing weight. After weight loss, like most other diets, you can’t go back to eating haphazardly because you’ll regain the weight. Surprisingly, it takes a lot of work for our bodies to store the fat that we eat as fat. Eating fat does not make you fat. (mic drop)

Leigh: So, would people with diabetes benefit?

Dr. Taylor: There is evidence that supports the use of keto in diabetes. Ketones are safe; it’s ketoacidosis that is dangerous.

Leigh: How can one be safe as a diabetic on a ketogenic diet?

Dr. Taylor: First, we should talk about the difference between type 1 and type 2 diabetes. Briefly, type 1 diabetes is an autoimmune disorder where the beta cells (cells that make insulin) in the pancreas have significant impairment or completely stop making insulin in response to sugar in the blood. Type 2 diabetes is when the cells of the body become resistant to insulin, meaning that the pancreas must produce much more insulin in response rises in blood sugar in order to transport it into the cell.

There is a very serious condition that can occur in uncontrolled type 1 diabetics known as ketoacidosis. Because of this condition, ketones are commonly thought of as bad or dangerous, but there is a big difference between ketosis and ketoacidosis. As we’ve discussed, our cells can burn either glucose (sugar/carbohydrates) or fat (in the form of ketones) for energy. Ketoacidosis is dangerous in uncontrolled type 1 diabetes in which blood levels of both glucose AND ketones are well above normal. This is a dangerous, potentially lethal, combination as high levels of glucose and ketones overwhelm the body’s ability to keep pH levels in a normal range. Ketoacidosis in type 1 diabetes is induced by the following:

  1. Ingestion of carbohydrates elevates blood glucose (sugar) levels.
  2. The pancreas does not produce insulin to drive the glucose into the cells, causing the body to think it is in a starved state.
  3. To compensate for the body’s perceived starved state, fatty acids are converted to ketones to use as an energy source.
  4. Because glucose is high and ketones are also being produced, the signal to shut down ketone production is severely impaired, resulting in extremely high production of ketones (~20+ mmol/L) and an overly acidic blood environment.

On the other hand, ketosis from following a ketogenic diet (without having type 1 diabetes) involves an elevation of ketones from what is normally ~0.1 mmol/L to anywhere between 0.3 to 1.5 mmol/L in the blood. The ketogenic diet provides a substrate that our cells can use and doesn’t result in the perceived energy crisis seen in DKA. Because ingestion of carbohydrates is low, glucose levels remain mostly normal while the brain and other tissue happily use the ketone bodies for energy. Ketones are more acidic than glucose, but that is okay at these levels since we are generally good at buffering the blood to normal pH levels.

It appears that the ketogenic diet may be safe and helpful in both type 1 and type 2 diabetes. First, a case study published a few years ago reported successfully treating type 1 diabetes in a 19-year-old male (Tóth & Clemens. Int J Case Rep Images. 2014). The patient previously utilized an insulin injection regimen and short-acting insulin for sporadic high glucose. Through 6.5 months on a vegetable-rich ketogenic diet, this participant maintained very tight glucose control and was able to incrementally reduce insulin usage until he came off of his insulin injections. (that’s insane, and unheard of) There were no adverse events reported. Interestingly, he also improved C-peptide production, which suggests that his pancreas regained some ability to naturally produce insulin. Similar findings have recently been published in a cohort of 11 type 1 diabetes patients (Leow. Diabetic Medicine. 2018). Disclaimer: This was all under STRICT supervision by a medical team. It is very important for an insulin-dependent diabetic to follow the recommended carbohydrate intake for their insulin dosage. Changes in eating patterns can affect insulin needs; therefore, making dietary changes like this must be done with a medical professional.

There was also this really cool study published by Stephen Phinney and Jeff Volek this year (Hallberg. Diabetes Therapy. 2018). Out of 349 type 2 diabetes patients, 262 patients were treated via a continuous care model that included a vegetable-rich ketogenic diet and 87 received usual care for type 2 diabetes. The patients on the ketogenic diet produced a blood ketone range of 0.5-3.0 mmol/L, demonstrated better diabetic control, and had significant reduction in diabetes medications when compared to the usual care group. The overall care model was labor intensive for the practitioners and researchers, but this study showed some pretty cool results for potential use of the ketogenic diet in diabetes treatment. They also, really focused on diet quality, which makes me think that there is long-term feasibility for the style of diet that the patients followed.

Leigh: So if someone is concerned about ketoacidosis, is it important to monitor ketosis and shift more slowly? 

Dr. Taylor: I can’t say that I’m currently a proponent for keto in type 1 diabetes as I feel there much more need for research, but the ketogenic diet itself should not induce ketoacidosis. However, if people with insulin-dependent diabetes did want to pursue this as a potential treatment, it would be imperative that they do so through a medical professional with significant knowledge in the area. Following a ketogenic diet will require adjustments in insulin dosage and strict adherence to the diet protocol.

There’s a line of thinking that if you’ve become unable to use glucose (sugar) as a fuel, which is what diabetes IS, then the ketogenic diet may be an alternative. Think of it like this: why give your body more fuel that you can’t use? In type 1, perhaps keto could serve as a therapy that would alleviate the need for insulin injections. In type 2, it seems that it is effective in bringing abnormally high insulin levels down due to decrease in need. 

Leigh: Does the ketogenic diet contradict the idea that a calorie is a calorie?

Dr. Taylor: On keto, the machinery used for getting glucose metabolism are reduced because you start using more of the fat and ketone metabolism machinery. Therefore, everything that we know about metabolism when we are primarily using glucose is turned on its head. One of the effects of the diet could be that we increase the number of mitochondria available, which is where the body makes energy.

Leigh: Is there a thermogenic effect?

Dr. Taylor: Ingesting more fat for energy makes you more likely to burn more of your stored fat as energy. Think of it this way: fat burning machinery is at its peak, so stored fat in our bodies become available as an energy source.

Leigh: Why do ketones make us make more mitochondria?

We still aren’t exactly sure why. Some theories include that ketogenic diets cause less metabolic stress allowing for more mitochondrial biogenesis or perhaps that ketones themselves have a signaling effect. It’s very important to keep in mind that all of the research available has been done in humans/animals with health conditions, not those that are generally healthy.

Leigh: Is there any evidence about the quality of the diet and efficacy of keto or is it all about the macronutrient balance?

Dr. Taylor: Right now, research outcomes have all been about macronutrient balance. I’d really like to see research go toward diet quality, which is coming. From a clinical standpoint (non-research), I’ve observed it is more feasible when people focus on quality, especially when following long term. A keto diet based on high quality foods would include beneficial fats, vegetables, and generally more of a whole food approach. These people seem to tolerate the diet better. They likely could go long term and have success, but we still need to learn if it’s feasible to follow a strictly ketogenic diet long term.

Leigh: Is there any effect on the gut while doing keto?

Dr. Taylor: Interesting new research about gut flora modulation suggests that some benefits of the ketogenic diet may be mediated/modulated by gut flora changes.

Leigh: What are the changes in flora?

Dr. Taylor: I’m not sure how it may affect people with an “optimal flora” but if you take, for example, epilepsy, MS, etc. it is suggested that the gut flora may be altered. In epilepsy, those changes in gut flora have associations with changes in seizure control. There are some animal studies where changing the gut flora can help halt seizures. This poses an interesting question: does diet quality in the ketogenic diet matter? Now we have to ask: do the microbes change by the macronutrient distribution, or does the food type matter (e.g. do veggies/fruit matter)?

My Journey: Thriving After Struggling with my Relationship with Food

my story photo.jpg

I can still picture sitting in class my senior year of college listening to my professor, Dr. Eunice Basler, display on the projector a description of “normal eating.”

 Copyright © 2018 by Ellyn Satter. Published at www.EllynSatterInstitute.org. You may reproduce this handout if you don’t charge for it or change it in any way and you do include the copyright statement.

Copyright © 2018 by Ellyn Satter. Published at www.EllynSatterInstitute.org. You may reproduce this handout if you don’t charge for it or change it in any way and you do include the copyright statement.

I will never forget that class.

I was a lean (teetering on underweight) college athlete. An anxious perfectionist who mentally tabulated every bite I took from morning until night. I analyzed and re-analyzed exactly what I had eaten and what I would eat. I was so consumed with what I ate that I didn’t have much mental space outside of that and school to think about much else.

Needless to say, I wasn’t the life of the party.

I can hear my friends snort with laughter reading this. Who am I kidding?! I rarely even went to parties (ok, fine, I like never did). I’d blame it on being an athlete, but the reality was that it was a combination of social social anxiety, perfectionism, and having some weird lack of FOMO in college. Who was I?!

My sophomore year of college I had actually changed my major from pre-business to nutrition because I found myself reading my friend’s nutrition textbooks.

I was obsessed.

I’ll be the first to admit that I came to studying nutrition out of an unhealthy relationship with food. I was the teenage girl watching morning television at home during the summers and listening to the morning talk show hosts talk about calories and weight loss and the dangers of being overweight. In my mind, they were talking to me. I was determined to never be overweight, and I knew (from their talk show lessons) that I could avoid that by counting every calorie that did, would or ever could pass my lips.

So, that’s what I did. I lowered my fat and calories as much as I could while fueling enough to get through track practice. Looking back, it is so sad, but at the time, I thought I was being healthy. Well, for every fat gram I eliminated I steadily lost the same amount of my sense of humor, my love for being active, my ability to feel feelings. I was felt completely numb.

Fast forward a few years to that classroom with Dr. Basler, staring at Ellyn Satter’s definition of “normal eating.”

I read these words on the projector and had a sense of relief. Normal eating is being overly full sometimes. It’s also feeling hungry. It’s eating something that you don’t really love or stopping when you’re satisfied.

During that class, we were assigned to read the book “Intuitive Eating” by Resch and Tribole, and that was another level of exploration. I could eat anything and that was ok. I could trust my body to tell me what it needed. I could pay attention to foods I loved and also take note of foods that I just didn’t enjoy.

You’re probably like “umm… duh! This is the life of a veggie hater!” I know. But, from the perspective of a fragile, perfectionist college nutrition student, eating something that was not “healthy” (in the classic sense, at the time) was unfathomable.

I seriously remember one of the girls in my sorority (sorry, I think it’s weird to say “sister”) casually eating a piece of cheese like it was no big deal, and I was like “how can she do that? Doesn’t she realize how much fat is in that?!”

Wow, Leigh. You’ve got problems.

Yes, I really did. And, I can honestly say that the class I took with Eunice Basler (paired with finding an amazing therapist) saved my health (mentally and physically). After taking her class, I ate what I truly wanted to eat and what I actually enjoyed. This, however strange it might be to read, was a big deal for me.

This allowed me to regain my life. I started thinking about things outside of classwork, my track training schedule (technically field, I was a high jumper), and what I was going to eat.  

Now, I can eat comfortably around others without anxiety. I don’t worry about calories, and I fully trust my body to tell me when I’m hungry or full and eat (or stop eating) accordingly. Sometimes I overeat (especially when my parents cook), and sometimes I undereat (especially when Rob and I haven’t planned). At times, I choose what to eat because it’s healthy, and other times (and now more often) I choose what to eat because it tastes good… healthy and tasty are definitely not mutually exclusive - check out my recipes. I, by no means, have a “perfect” relationship with food, and I never will. But, I know that I eat “normally,” and that’s what’s most important to me (and my mental health).

So, how did I get to this point?

Well, it’s taken a lot of time, hard work, appointments, honesty, reading, listening, and a wonderful support system of friends and family (seriously, I know how lucky I am). Here are some of my main self-help mechanisms:

  • Read the definition of “Normal Eating” by Ellyn Satter

  • Read Intuitive Eating by Evelyn Tribole and Elyse Resch

  • Sought counseling with a licensed therapist

  • Received massage therapy (it was helpful to develop a healthy relationship with my body and it continues to be an important part of my self-care)

  • Talked with friends and family I could trust about my struggle

  • Continued to read and listen to self help-type books. Some of them:

I remember one of the breakthrough moments of my progress after I had started therapy in college. It was after I finished jumping at a track meet where I jumped worse than I ever had, even in high school. My parents had come to the meet, and after changing out of my high jump shoes I went over to sit with my mom in the stands and I literally sobbed in her lap for a good 20-30 straight minutes. I remember thinking how relieved I was to actually feel feelings. That’s how numb I was. I remember when I finally laughed again, felt the feeling of being annoyed, and being grateful because I actually had feelings again.

If you can relate to an unhealthy relationship with food, the bottom line is that you’re not alone, and I want to support you to get help. It’s definitely a journey without a final destination.

I’d never wish on anyone the struggle I’ve gone through (and I also know that many others have had a much harder and riskier journey than mine), but I’ll always be grateful for it. I would never be who I am today without it, and I know that I am better able to help my clients because of what I’ve gone through.

I realize that now most of my work as an integrative and functional medicine dietitian revolves around helping clients identify foods that cause inflammation and/or dietary problems to address chronic disease. Sometimes (often) this involves elimination diets - possibly the antithesis of intuitive eating?

So, this isn’t the end of the story, because our relationship with food is complicated.  I'll share the next chapter in another post, but it involves interviews and input from experts like Ellyn Satter, Evelyn Tribole and other experts who know a lot about how people develop healthy relationships with food and eating.

I’m excited to share more.

Misapplied Information is a Bigger Problem than Misinformation

Copy of Copy of Magnificence.png

To be completely honest, there’s a ton of really good information available to us. Yes, there’s click bait and spammy junk. But, you can also access pubmed abstracts and sometimes even full articles. Many of the most well respected schools and institutions provide free training and information online (Stanford, Mayo Clinic, Cleveland Clinic and others).

And although there’s some training involved in navigating through the nuance of scientific studies, what I’m more concerned about is the misapplication of good information.

What I mean is this: We see others close to us (friends, family members, people we stalk on Instagram) make diet, exercise or other lifestyle changes. We think: well, I like them, trust them, admire them and I want their results. I SHOULD DO WHAT THEY’RE DOING!

What we don’t realize is that their metabolism, genetics, health, family and life histories, and myriad other things are different than ours. We’re AREN’T THEM! And--news flash--that’s a GOOD thing. So, I’d say if you try a new way of eating and it just doesn’t quite feel right, what your body tells you are hints to you that maybe something isn’t quite right.

So, although there’s unending good information available to us now, we should check in with ourselves and honor what your body and intuition tells us. Is this right for ME or someone else?  

Paleo is Not for Everyone

paleo is not for everyone.jpg

I recently saw a friend post this photo on instagram of a beautiful spinach salad with avocado, eggs, tomato and a caption that made me cringe (both as a friend and as a nutritionist): “Working our way through Day 11 of this horrible Whole 30 plan. I don't know what will be more of an accomplishment - Finishing or getting my husband to eat Spinach, Kale and Broccoli for 30 days. #thisdietsucks#wearenofun #seeyouinfebruary.”

I was having dinner with another friend last week, and I think she almost fell off her chair when I told her that I feel better when I eat a little bit of whole grains in my diet. She was surprised because so much of the messaging right now is to avoid grains and go super low carb. And, when I say I think I feel better when I have some grains in my diet, I don’t mean a bowl full of “whole grain Lucky Charms” cereal that I’ve seen on packaging in the grocery store. I’m talking about actually cooking whole oats or wild rice or quinoa. Now, some clients I work with get bloated just hearing the word “oats” or “rice” or “quinoa,” and those are people who I think may benefit from giving a grain-free diet a try. But, it’s only worth the time, effort, and discipline if it would make that person’s life better (not being bloated after every time they eat) and not worse (being mad for an entire month of the year).

News flash: the paleo diet is not for everyone. It’s not. And, a vegetarian or vegan diet is not for everyone, either. I’m not saying it isn’t important to eat whole, real, unprocessed foods. I’m just saying that the paleo diet is not for everyone. And, it’s not for everyone for several reasons. It’s not because it isn’t (or couldn’t) be healthful when carefully planned. It’s not just because every person’s body is different (which it is and that could be a reason why it could be for you). It’s not just because it’s “expensive” to eat real food (and that argument is for a different blog post). It’s because when diets are approached as a sentence to be served or when diets cause more stress than relief (or joy), then it’s just not for you. Here are my initial thoughts…

Your Diet (the way you eat) Shouldn’t Piss You Off

I tell clients and patients (and friends and family who ask me) that making dietary/nutrition/lifestyle changes are a choice. You’re doing this of your own volition. You’re choosing to make these changes. No one else is choosing it for you, and no one else can choose it for you. If it makes you physically or mentally stressed, upset, angry, frustrated, annoyed, or any other negative adjective, then it’s not for you, or at least it’s not for you right now.

On the flip side, if you need to attempt a dietary change like this to see if it could help relieve physical symptoms you’re experiencing, then you may need to push through the challenges of these new dietary changes for enough time to see if it makes a difference for you (I typically say 6 weeks for adults – kids tend to be more resilient). In that case, then you just need to ignore the jeering comments and jokes. You just keep your eyes on the prize and get through it with the support of your nutritionist and, hopefully, friends and family.

Your Dietary Needs Are Not the Same As Your Neighbor’s

Whenever I’m giving a presentation to a large group, as I get further and further into my presentation, folks in the audience start wondering (and asking aloud) what I think they should eat. I always have to remind the audience that every single person in the room has a unique metabolism, biochemistry, gut, health history, lifestyle, family, family history (genetics), and every other aspect of their lives are unique to each person. Similarly, the paleo diet may be healthful and helpful for your coworker or friend, but it may not be healthful for you.

Food is a Social Act (not solely a physical need)

When I notice that some of my clients stop seeing friends or being social like they used to be, I make sure and check in with them. Our health is not just about what foods we put in our body, it’s also about how the food is shared and enjoyed (yeah, it should be enjoyable to taste your food – even healthy foods).  When you stop spending time with friends, then you’re missing an important health need: fellowship and community.

The Bottom Line

A paleo diet could be a healthy choice for you. It might help alleviate pain, lose weight (if you need/want to), fix digestive problems, or generally make you feel better about the way you’re living your life. That being said, every person’s health is his or her own individual journey, and we all need to find what is both physically and emotionally “right” for each of us. The paleo (or vegetarian or omnivorous) diet may fit those needs for you, but if you try it and you hate it, or it doesn’t make you feel better, then it’s not right for you.

What’s the Magic Health Pill?

what's the magic health pill.JPG

My take on the popular 2017 food and health documentaries: comparing and contrasting the high points. 

Over the past year, I’ve had people from all seasons of my life reach out to me and ask me what the H I think about the “What the Health” and “The Magic Pill” documentaries.

I have to be honest… I didn’t even watch them. Although I’m obviously pretty interested in nutrition, health, and what we can do to reverse chronic disease, I sometimes need to just watch a binge-worthy documentary on Netflix (um… Wild Wild Country and Evil Genius anyone?!). I just need to shut off from all of that. Plus, I get to the point where I only need to watch 5 minutes of a documentary, see which “experts” they’ve interviewed, and I can already predict the bent to the show.

So, I finally bit the bullet. 

I picked these 2 out because they’re 2 of the most popular/high impact (people are making big health/diet decisions based on watching these), and they were both published in 2017. Other food and health-related documentaries I could have talked about include Fat Sick and Nearly Dead, Food Inc, Fed Up, Forks Over Knives, Cowspiracy, King Corn, That Sugar Film, and honestly more than I realized existed before watching each of these.

I had an intern working with me the past couple weeks, and we sat down to watch them (lucky her, right? You’re assignment is to relax on my couch and watch movies with me). Together, we put this table (below) to compare and contrast the two documentaries. If you’re unlikely to read through the table, let me summarize it briefly here for you:

Ok, first before I go any further, I want to acknowledge that this is a very high level summary of what I see as the main themes, similarities and differences between the two documentaries. This is by no means comprehensive, and there is definite nuance to each.

So, now that we have that out of the way, here we go:

What the Health (WTH) claims that a vegan, plant-based diet is the best health approach to eating. You should eat zero animal foods, and any chronic disease that comes from poor eating comes from foods derived from an animal. Sugar doesn’t matter. Eat all you want. You can see in the table that WTH is most concerned about processed animal products without concern for processed or refined carbohydrates. WTH would say that there is also no difference between organic or conventionally-raised foods.

The Magic Pill (TMP) claims that an ancestral “paleo” or ketogenic-type diet is the most healthful. Get back to the way we’ve historically eaten and let our genes lead the way. TMP would care more about highly processed/refined foods, overall. Quality of food is the higher priority over whether foods are animal or plant-derived.

Both documentaries hold big ag and big industry (pharmaceuticals and food) responsible for the cultural drive for this way of eating. They also both emphasize minimizing highly refined or processed foods (whether meat or carb). They both tell compelling stories of individuals who have dramatically changed their diet to follow the purported “best” way to eat, and you watch these people share how the diets have transformed their lives, leading to lower pain, less medication, and an overall better quality of life. Both documentaries tell compelling stories, and that’s what we all love. I can see why people choose to change their diets after watching either!

My take away: each of them emphasizes the importance of plant foods. Although they don’t address it in either movie we need to be mindful of the idea that you can eat a “healthy” version of either of these “diets,” and you can eat a less-healthy version (soda & chips are vegan and bacon & cheese are keto). So, using some common sense with their application is always important.

So, What is the Magic Health Pill? I'm sure you can guess what I'll say, but there's no short cut to wellness, and eating more plants and less processed foods is always going to be a good way to approach your diet. The evidence is consistent in the literature that eating more plant foods is associated with better health outcomes. So, if you've never eaten your veggies, it's never too late to start.

I would say that if you’re unsure of what to do, just take a look at what you’re eating on a weekly basis (maybe keep a weekly log), and also pay close attention to how you're feeling. Do you have good energy, focus, good digestion? If not, your lifestyle may be playing a role in how you're feeling. As far as how you're eating, if half or more of what you eat is coming out of packages or windows (drive-thrus), then maybe a change would be worth it? If you’re eating mostly whole, minimally processed/refined foods, then you likely have a solid foundation. My only word of caution for the dietary approaches from each documentary is that they can both leave us vulnerable (similar to a Standard American Diet) to nutritional deficiencies if left unmonitored over a long period of time. There's no "one size fits all" approach to lifestyle changes, especially when it comes to diet. Integrative and functional healthcare practitioners are best equipped for monitoring and evaluating your nutritional status and would be a great sounding board for your efforts.

I know a really good nutritionist, if you’re looking for one...

So, what did you think about the documentaries? Have you made any changes since watching either or both of them?

Debunking the Myths of Hypothyroidism

Before reading this post, I need to give a little background:

I'm always asked my opinion about thyroid nutrition, so this post is a
little (itty) bit of what is known about thyroid nutrition. There's so much out there! 

I wrote this for an Integrative and Functional Nutrition
newsletter, so remember that my original audience was healthcare
providers.  I can get a lil science-y/jargon-y.

Oh, and if you want to learn more, check out the book Hashimoto's Thyroiditis: Lifestyle
Interventions for Finding and Treating the Root Cause
by Dr. Izabella
Wentz PharmD (she also wrote an article about Subclinical
Hypothyroidism in the same newsletter where this will be published).
Her book is gold.

Ok, enjoy!(?)

Debunking Myths of Hypothyroidism

Leigh Wagner MS, RDN, LD

Hypothyroidism is a common and burdensome health condition. Symptoms of hypothyroidism include constipation, dry skin, muscle pain, brittle hair, hair loss, fatigue, and difficulty losing weight. Since one in 300 people (NHANES III)1 and nearly 10% of adult women have hypothyroidism,2 it is important to address some of the myths surrounding the disease. The following are some common myths and a brief summary of evidence to address the controversy or misconception.

Myth: Everyone with hypothyroidism needs iodine supplementation.

Iodine is required for healthy thyroid function, and iodine is most highly concentrated within the thyroid gland. Thus, adequate iodine levels are important for the thyroid to work properly. One situation where clinicians should be cautious with iodine supplementation is in the presence of anti-thyroid antibodies. Persons with elevated anti-thyroid antibodies are at increased risk of experiencing negative effects of iodine supplementation.3 In other words, when a person has elevated anti-thyroid antibodies, he or she should be wary of high, long-term iodine intake. Therefore, persons with hypothyroidism should be tested for the presence of anti-thyroid antibodies prior to iodine supplementation.

Myth: Anyone in the U.S. eating commercially prepared foods or consuming dairy products regularly gets enough iodine from salt or dairy foods.

Although iodized salt is widely available, salt iodization is not mandated in the U.S.4 Most food companies use non-iodized salt in their foods.5 As a result, Americans may not consume as much iodine through salty, processed foods as once thought.

Like salt, dairy foods are assumed to have high amounts of iodine because, historically, iodine has been supplemented in dairy cattle, and iodine-based disinfectants were used in tanks for dairy transportation. However, cattle are not as widely supplemented, and the iodine-based disinfectants are often replaced with chlorine-based antiseptics.6 As such, dairy cannot be considered a dependable source of iodine in the U.S. food supply.

Myth: Iodine deficiency is the main cause of hypothyroidism in the U.S.

Although worldwide iodine deficiency is a major factor for hypothyroidism, in the United States, Hashimoto’s thyroiditis is the primary cause of the disease.1 Keep in mind that one sign of iodine deficiency is low thyroxine (T4).6 When possible, doctors should check urinary iodine levels (preferably 24-hour urinary iodine) to determine iodine status. Knowing iodine status can help determine whether iodine supplementation is warranted.

Myth: People with hypothyroidism should avoid all goitrogenic foods.

Goitrogens are compounds in foods that inhibit thyroid function. When a person has hypothyroidism or is at risk for thyroid dysfunction, it may be recommended that they decrease goitrogenic foods. Goitrogenic foods primarily include soy, millet, and cruciferous vegetables (broccoli, cauliflower, cabbage, Brussels sprouts, mustard, kale, collard greens, kohlrabi, bok choy, rutabaga, and turnips).7 Although a person with hypothyroidism should be cautious of the amount of goitrogenic foods consumed, he or she can continue to eat cruciferous vegetables, as long as the vegetables are cooked. Cooking generally decreases cruciferous vegetables’ goitrogenic effects.2 Unfortunately, soy’s goitrogenic activity is not affected by heating or cooking,8 and cooking millet actually increases its goitrogenic activity.9

Myth: People with hypothyroidism should avoid soy completely.

Soy is commonly known to affect the thyroid gland.10 Its isoflavones (phytonutrients in soy) affect thyroid peroxidase (TPO),11 which is involved in the synthesis of thyroid hormones (T3 and T4). If there is a concern about the anti-thyroid effects of soy, clinicians should know that persons with deficient iodine levels are at higher risk for soy’s negative thyroid effect compared to iodine-replete individuals. Thus, iodine levels should be checked in individuals with hypothyroidism.

Myth: If thyroid stimulating hormone (TSH) is elevated but T4 is normal, then thyroid function is normal.

Subclinical hypothyroidism (SCH) is not a medical diagnosis but is defined biochemically as elevated thyroid stimulating hormone (TSH) with normal free thyroxine (fT4).12-14 Depending on the level of TSH elevation, SCH can be mild (4.5-9.0 mU/L) or severe (≥10 mU/L).13 Its prevalence varies widely, ranging between 4-10% in the general adult population and as high as 20% in older women.15-17

Despite the fact that SCH is not a medical diagnosis, SCH increases risk for cognitive impairment,18 cardiovascular disease,19 and for progression to overt hypothyroidism.1,13 Although screening and treatment recommendations vary,20-22 most experts recommend treatment with thyroid hormone (L-T4) at TSH >10 mU/L because higher TSH levels make progression to overt hypothyroidism more likely. When TSH is between 4.5 and 10 mU/L, treatment is typically left to clinicians’ judgment.17 Patients with both SCH and vitamin D deficiency also have increased cardiovascular risk.23

Myth: Measuring TSH is the only important test to screen for thyroid function.

Although TSH “with reflex T4” (i.e. when TSH is out of range, the laboratory will be triggered to test T4) is a commonly used lab test among clinicians, integrative medicine practitioners suggest to test, at a minimum, TSH, free T3, free T4, TPO antibodies, reverse T3, and possibly minerals like iron and zinc. Also, note that TSH is highest typically between 10 pm and 4 am, and it is lowest between 10 am and 6 pm.24

Take Home

The thyroid is a complex gland, and its activity influences more than metabolism and weight management. A healthy thyroid can influence cardiovascular health, cognitive function, bone health, and keep one feeling vibrant and energetic. Both the public and clinicians alike are easily overwhelmed and sometimes confused by conflicting information in the media. The information provided in this article is likely to change as we continue to learn more about the thyroid and the foods and nutrients that affect its function. Since nutritional science is evolving and growing, clinicians must stay up-to-date on thyroid-related clinical guidelines and existing science to help individualize patient care and to address the recurrent myths that circulate.

References

1. Gaitonde DY, Rowley KD, Sweeney LB. Hypothyroidism: an update. Am Fam Phys. 2012;86(3):244-251.

2. Escott-Stump S, Giroux I. Nutrition and Diagnosis-Related Care, 7th Ed. + Applications and Case Studies in Clinical Nutrition. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

3. Leung AM, Braverman LE. Iodine-induced thyroid dysfunction. Curr Opin Endocrinol Diabetes Obes. 2012;19(5):414-419.

4. Leung AM, Braverman LE, Pearce EN. History of U.S. iodine fortification and supplementation. Nutrients. 2012;4(11):1740-1746.

5. National Institutes of Health: Office of Dietary Supplements. Iodine:fact sheet for health professionals. https://ods.od.nih.gov/factsheets/Iodine-HealthProfessional/. Reviewed June 24, 2011. Accessed July 27, 2015.

6. Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diab Endocrinol. 2015;3(4):286-295. DOI: http://dx.doi.org/10.1016/S2213-8587(14)70225-6.

7. Higdon JV, Delage B, Williams DE, Dashwood RH. Cruciferous vegetables and human cancer risk: epidemiologic evidence and mechanistic basis. Pharmacological Res. 2007;55(3):224-236.

8. Divi RL, Chang HC, Doerge DR. Anti-thyroid isoflavones from soybeans. Biochem Pharma. 1997;54(10):1087-1096.

9. Gaitan E. Goitrogens in food and water. Ann Rev Nutr. 1990;10:21-39.

10. Messina M, Redmond G. Effects of soy protein and soybean isoflavones on thyroid function in healthy adults and hypothyroid patients: a review of the relevant literature. Thyroid. 2006;16(3):249-258.

11. Doerge DR, Chang HC. Inactivation of thyroid peroxidase by soy isoflavones, in vitro and in vivo. J Chromatogr B Analyt Technol Biomed Life Sci. 2002;777(1-2):269-279.

12. Surks, MI Ortiz E, Daniels GH, et al. Subclinical thyroid disease scientific review and guidelines for diagnosis and management. JAMA. 2004. 29;2:228-238.

13. Cooper DS, Biondi B. Subclinical thyroid disease. Lancet. 2012. 379:1142-1154.

14. Cooper DS. Subclinical hypothyroidism. NEJM. 2001;345:260-266.

15. Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T4, and Thyroid Antibodies in the United States Population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrin. 2002;87(2):489-499.

16. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado Thyroid Disease Prevalence Study. Arch Intern Med. 2000;160:526-534.

17. Gharib H, Tuttle RM, Baskin HJ. Subclinical thyroid dysfunction: a joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society. J Clin Endocrinol Metab. 2005;90(1):581-585.

18. Resta F, Triggiani V, Barile G, et al. Subclinical hypothyroidism and cognitive dysfunction in the elderly. Endocr Metab Immune Disord Drug Targets. 2012;12(3):260-267.

19. Rodondi N, den Elzen WP, Bauer DC, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010;304(12):1365-1374.

20. Ringel MD, Mazzaferri EL. Subclinical thyroid dysfunction--can there be a consensus about the consensus? J Clin Endocr Metab. 2005;90(1):588-590.

21. Cooper DS. Subclinical thyroid disease: consensus or conundrum? Clin Endocr (Oxf). 2004;60(4):410-412.

22. Chu JW, Crapo LM. The treatment of subclinical hypothyroidism is seldom necessary. J Clin Endocr Metab. 2001;86(10):4591-4599.

23. Yilmaz H, Cakmak M, Darcin T, et al. Subclinical hypothyroidism in combination with vitamin D deficiency increases the risk of impaired left ventricular diastolic function. Endocr Regul. 2015;49(2):84-90.

24. Rakel D. Integrative Medicine. 3rd ed. Philadelphia, PA: Saunders, Elsevier; 2012.

Why Keto is Everywhere Right Now

Ok, so if you follow my Instagram, you know that I took a poll to decide whether I should blog about the ketogenic diet or the documentary “What the Health.” And, keto won, if only slightly. So, my hope is to give a really high level overview about keto with a few zoom-ins (without writing an entire referenced review article - but there are some references). I’m also hoping this will help you look good at dinner parties when someone’s diet endeavors inevitably come up.

So, here we go.

As with most diets or “lifestyle changes” (as we love to call them in the biz 😜), diets often run in cycles, come and go. We have low fat, low carb, high protein, and every other nuanced permutation of different macronutrient (carb/fat/protein) amounts.

Well, what’s a little different about the ketogenic diet, is that there’s some compelling evidence suggesting that it may be super helpful for some people with certain diseases (some (not all) cancers, Alzheimer’s, and the OG therapeutic keto condition: epilepsy).

And, with that being said, one reason keto is becoming increasingly popular recently is because it can also help facilitate weight loss... and thus, you can't escape it. Keto is everywhere right now. 

Ok, but before I get into that (and why), let me explain what the ketogenic diet, or “keto,” is.

The ketogenic diet is a diet that’s very high in fat (like 80% of your daily calories are fat), very low carb (like 5%) with moderate-to-low protein (like 15%). The idea (and reason it’s called “ketogenic”) is because the body, when restricted nearly completely of carbs, will shift into burning an alternative energy source called “ketones.” It’s like a flex fuel car.

So, ketones (sometimes called “ketone bodies”) are just tiny parts of fats that are broken down differently than normal (into 2 carbon molecules), and instead, they’re broken down into 3 carbon compounds… called “ketones.”

INTERESTINGLY, (for a nutrition nerd), ketones can be burned by the body (and the BRAIN - even though I was told in conventional nutrition school that our brains only run on glucose), and the body is able to burn fats more easily that we have in reserve (think stored fats… like in our bellies, butts, and thighs). I like to call this “fat burning mode.” So, our bodies can use this alternative metabolic process (ketone production), and we don’t have to use sugar/carb to function.

So, the reason I brought up the idea of diets coming in and out of style is because… remember the Atkins diet? Yeah, this is a ketogenic diet. To give you an analogy, Kleenex® is a brand of tissue, while Atkins® is essentially a brand of ketogenic diet. Does that make sense? And, apparently, (one of my clients told me), the original Atkins diet instructed you to buy ketone strips (urine testing strips to measure if you’re making/burning ketones). So, the “keto” diet in popular culture is really just the Atkins diet coming back around. Although, I would say that when I use the ketogenic diet therapeutically, I encourage clients to focus on high quality fats and oils (coconut oil, extra virgin olive oil, organic pasture butter, avocado oil, nuts and seeds) whereas I always remember people on the Atkins diet just eating cheese and bacon. Although, now as I'm looking around on social media at "keto" posts, it's confirming that there's a lot of bacon and cheese (palm to forehead).

Ok, side note for the people who have diabetes or have family members who do… don’t freak out on me too soon…you’re probably thinking about Diabetic ketoacidosis.

Metabolic ketosis is NOT the same as diabetic ketoacidosis. Diabetic ketoacidosis is a very serious, dangerous problem and will lead to severe symptoms. Please work with your physician or integrative dietitian 😉 before you make any dietary changes.

So, here’s the deal with the weight loss stuff (and I’m going to be brief, because I already lost half of you). With other “diets” (like low fat or long-term low calorie diets), the body will adapt and lower its metabolic rate. On the other hand, with a very high fat, low carb diet, the body will maintain its metabolic rate (and lean body mass) and still allow weight loss.

From a 2018 article in the Journal of the American Medical Association (JAMA):

“…there are hints that the ketogenic diet may be different [than other diets]. A meta analysis of 13 randomized controlled trials suggested that people on ketogenic diets tend to lose more weight and keep more of it off than people on low-fat diets. People placed on these diets often report decreased hunger.”

But, before you go jumping on the keto bandwagon (really, I don’t encourage everyone to do this), remind yourself of how appalled/surprised you were that this diet is 5% carb and 85% fat. I’m not saying you should be scared of a high fat diet (I eat a ton of it!), but I am saying that eating a really high fat, low carb diet in America in 2018 could be challenging over the long term.

Instead, what’s most likely beneficial is that you not eat the same food all the time. Just like I told you that long-term calorie restriction can lower your metabolic rate (meaning our bodies burn fewer calories by adapting to protect itself from this contrived famine we’ve put ourselves on), if you eat more of a variety of calories, variety of macronutrients, variety of foods, at various times of day, and in various amounts… that’s probably even better for us.

If you’re a fitness junkie, you can think of this as “cross training” or always keeping your body guessing and not adapting to your 5-mile run you do everyday. The body will adapt and may not benefit as much from the exercise – you always need to “switch it up.” 

As with any diet, you can follow a whole foods-based version (lots of plants, healthy fats and oils, and good quality protein) or you can follow a less healthy version: vegans can eat potato chips and drink Coke and paleo dieters can eat bacon and cheese all day. I think you get the picture.

So, keto can absolutely be a helpful for certain people with guidance from someone skilled in using the diet therapeutically (I've seen it transform lives). There are tons of resources out there, but always keep in mind that often people are promoting what works for THEM and don’t get to tied up in that – you need to do what works for YOU.

So now that you have the basics of keto, have fun at your dinner party!