The Paleo Diet is Not for Everyone

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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

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.

Paleo: 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?

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My take on What the Health and The Magic Pill, two popular food and health documentaries

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 hadn’t even watched 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? Your 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 summary

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 summary

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.

Is there a magic health pill?

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. 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!