Reflections on Being a Nutritional Centrist

INTRODUCTION: In a recent article titled Carbohydrates are not Evil I referred to myself as a “nutritional centrist” and in this post I’ll elaborate on what I mean by this. This post is more of an editorial than a standard ‘Science Made Simple’ article. References can be found in the previous articles by using the search feature.


Much of the discussion about nutrition these days on social media seems to take an “all-or-nothing” stance.

As in politics, there are those that tend towards a “left-wing” (liberal) position and others who tend towards a “right-wing” (conservative) position; some who are libertarian (let people decide for themselves) and others who are very authoritarian (dictate what they believe is best).

When it comes to nutrition, I am a centrist.

Defining Nutrition Centrism
In this article, I am using the term "centrism" to include a very wide range of nutritional positions apart from any at extreme ends of the spectrum. I believe that a wide range of nutritional centrists positions are supported by current, evidence-based science.

Veganism and Carnivory – two ends of the spectrum

In the food world there are vegans on one hand and carnivores on the other.  One eats only plant-based food with nothing coming from animals (no eggs, milk or cheese) and the other eats only animal flesh food (no fruit, vegetables or dairy). These can be looked at as the nutritional equivalents to ” left wing” and “right wing” political positions. While I respect people’s individual right to choose veganism or carnivory as a lifestyle, for health reasons, or on the basis of ethical or religious beliefs, in my understanding there are significant nutritional challenges to both ends of the spectrum.

Nutritional centrists – vegetarians, pescatarians and omnivores

Somewhere between veganism and carnivory are vegetarians
(who eat mostly plant-based foods but will also eat eggs, milk and cheese because no animal is killed or harmed in the making of these) and those who are omnivores (that will eat food from a wide variety of plant and animal sources). Somewhere in the middle of these two are pescatarians who are like vegetarians but who will also eat fish (perhaps because they are not mammals, and sometimes only when they are wild species i.e. not man raised).

From my perspective, people who chose any of these lifestyles fall somewhere in the “nutritional centrist” position. I find it easy to support people following any of these lifestyle or ethical choices because it is possible to design a diet that ensures adequate nutritional intake of a wide range of macro- and micro-nutrients from the foods they choose to eat.

Whole-food-plant-based

Those who follow a “whole-food plant-based diet” can be either vegan or vegetarian so in my understanding, whole-food plant-based vegetarians fall somewhere in the “nutritional centrist” position, whereas whole-food plant-based  vegans are vegans with an approach that falls at one end of the spectrum.

Low Carb High Fat and Ketogenic diets – a centrist approach

As I’ve mentioned in numerous previous articles, there are several different types of “low carb” and “ketogenic” diets.

For example, if a client comes to me with a dietary prescription from a physician for a specific type of ketogenic diet to support a specific medical or metabolic condition that is a very different scenario than someone who wants me to help them with “quick weight loss” using a “keto diet”.

As a “nutritional centrist” my approach to supporting people in following a low carbohydrate lifestyle for weight loss is to start at a moderately-low level of carbohydrates (130 g carbohydrate per day) and lower the amount of carbohydrate as needed to achieve clinical outcomes. If individuals are insulin sensitive, this level of carbohydrate intake often works very well, especially at first when people were formerly eating ~300+ g of carbohydrate per day. For those who are insulin resistant or have Type 2 Diabetes, I start at a moderately-low level of carbohydrate intake and with self-monitoring of blood sugar and follow-up and oversight from their doctor with respect to any medications taken, will gradually lower carbohydrate intake as needed to achieve the desired clinical outcome(s).

It is not a “one-sized-fits-all” approach. As documented in several previous articles, people’s glycemic (blood sugar) response to carbohydrate varies significantly, even among those who are insulin sensitive and also in those with Type 2 Diabetes, so determining individual blood sugar response to carbohydrate is the best way to determine which types and amounts of carbohydrate people respond best to. I don’t believe it is appropriate or necessary for everyone to follow a “keto diet”.

Nutritional Centrism with respect to added fat

Amongst those that teach and support a “low carb” lifestyle, there are those that promote lots of added fat from a wide variety of sources.  These are people that believe in adding coconut oil and butter to beverages, butter to top meat and vegetables and using whipping cream copiously. From the beginning this is not an approach I have taken. In light of the recent scientific evidence (such as the large-scale PURE epidemiological study and others), I do not believe that moderate saturated fat intake is harmful to cardiovascular health. At the same time, I see no reason that if added fat is helpful in a particular person’s diet, that fats such as cold-expressed olive and avocado oil as well as nut and seed oils such as macadamia, walnut and almond oil aren’t suitable options.

I don’t see the need for extremes with regards to added fat. I encourage people for whom the recommendation is appropriate to add enough good quality healthy fat to make the vegetables or salad taste interesting enough that they will want to eat a fair amount of them and enjoy them. After all, eating isn’t only about getting enough nutrients, but enjoying the foods that are eaten.

Fat that comes with protein

Unless there is a medical or metabolic condition involved which precludes it, I encourage people to eat the fat that comes naturally with their protein source if they enjoy doing so.

I encourage folks to trim excess external fat off a fatty cut of steak, but if they enjoy chewing on the bone on a rib steak to ‘go for it’. The yolk in an egg or the fat in cheese is not harmful when eaten in moderate amounts so unless there are strong risk factors, I don’t believe people need to avoid or limit these foods.

While the new Canada Food guide recommends limiting foods with saturated fat based on the fact that dietary saturated fat raises total-LDL cholesterol, as I’ve documented in several previous articles I don’t believe when considering all the recent evidence that there is compelling reason to advise all people to limit foods containing cheese or to select plant-based foods over foods that contain saturated fat.

As mentioned in a few recent articles, Canada Food Guide is directed towards a healthy population in order to help them stay metabolically well and I believe that the whole-food approach of the new Guide which avoids refined grains, fruit juice and processed foods is a good evidence-based approach to accomplishing this, and one I support in my practice.

My concern as covered recently is that as many as 88% of Americans are already metabolically unwell (with presumably a slightly lower percentage in Canada due to our slightly lower obesity statistics) so in those that already have indications of insulin resistance (which is a large percentage of my client base), I do recommend a whole-foods approach but with a lower percentage of carbohydrate intake.  In my understanding, this is a “nutritional centrist” approach which is supported by the American Diabetes Association and the European Association for the Study of Diabetes who both support the use of a low carbohydrate diet as Medical Nutrition Therapy in the management of Type 2 Diabetes and for weight loss.

Supporting lifestyle choices

Veganism, like carnivory is a lifestyle choice that is sometimes made for religious or ethical reasons and sometimes for health reasons.  Regardless of the reason for the choice, these are lifestyles that need to be respected and supported by healthcare professionals who are qualified to do so.

As a “nutritional centrist” I can help healthy individuals follow the new Canada Food Guide and provide meals for their family along those lines if they so choose, as well as to support those who are already metabolically unhealthy using everything from a Mediterranean diet, a whole-food plant-based approach or a low carbohydrate or ketogenic diet. There is no “one-sized-fits-all” diet for any of these approaches and each should be tailored to individual needs.

No Conspiracy Theories

Conspiracy theories abound in many areas from religion to politics and there are plenty in the nutrition arena, as well. As a “nutritional centrist“, I don’t believe that “big-pharma” and “big-food” are behind everything, but at the same time I am also not naive enough to think that industries and special interests groups don’t attempt to influence the marketplace or government funding or policies by the types of research they fund, or by other means. I give scientists and researchers the benefit of the doubt that their intentions are in the interest of good science and the public interest, even though on occasion it is found out otherwise.

No Conspiracy Theories

My writing about topics such the funding of the Harvard studies by the sugar industry does not mean that I believe the scientists involved deliberately wrote biased reports. The articles were written to document the fact that researchers were funded by the sugar industry to write articles about why saturated fat was the underlying issue with respect to cardiovascular disease. Likewise, the recently translated French language newspaper report that shed light on why the government (e.g. Agriculture Canada or a political party’s leadership) may have been motivated to encourage the highlighting of legumes does not mean anything inappropriate occurred.  In my understanding, conspiracy theories are not compatible with a “nutritional centrist” position.

I would encourage my readers to give scientists and researchers the benefit of the doubt when it comes to their intentions; unless there is very credible and verifiable reasons to believe otherwise.

Libertarian versus Authoritarian Approach – a centrist approach

libertarian approach to dietary choice supports each person’s individual’s right to choose the most suitable dietary approach for themselves whereas an authoritarian approach essentially tells a person what is best for them.

As a “nutritional centrist“, I am frequently in the scientific literature, reading and reviewing the latest studies and evaluating these in light of what is already known about nutrition. My motivation in writing articles that put these studies into “plain English” is that so ordinary people can evaluate these in light of what they know and choose what they feel is best for them. From my perspective, the current available quality research on the subject is the “authority” but by no means should this be used in an authoritarian way to tell a person what is best for them. My position as a “nutritional centrist” is that people should be presented with the range of available evidenced-based options and the supporting science behind those options, but in accordance with a libertarian approach, the choice is theirs to make.

I hope that as a result of reading this article, you have a fuller understanding of what I believe and why and that I support a range of evidence-based dietary approaches including those who want to follow the Canada Food Guide, a Mediterranean approach, a whole-food vegetarian plant-based approach or a low carbohydrate approach and that include moderate amounts of healthy fats of all types. There certainly isn’t a “one-sized-fits-all” dietary approach suitable for everyone so from my perspective, the issue is which one may be best suited to help you achieve your health and nutrition goals, within your personal food preferences.

If you would like to know more about the services I offer, please click on the Services tab and if you have questions related to those, please feel free to send me a note using the Contact Me form located on the tab above.

To your good health!

Joy

Feedback and question from Dr. Andrew Samis, MD, PhD – shared with prior permission

UPDATE: February 1, 2019 13:20

Dr. Andrew Samis, MD, PhD, a surgeon and critical care specialist from Kingston, Ontario asked a very interesting question on Twitter, in response to this article;

Could the same eating strategy be healthy for one person, and make a second metabolically unhealthy?”

This was my response;

Yes, I believe there is ample evidence that the same eating strategy could be healthy for one person and make a second person metabolically unhealthy. Monitoring metabolic markers enables us to catch this early and make adjustments, as necessary.

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Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

Quebec newspaper:”no coincidence” dried beans so prominent in new Canada Food Guide

DISCLAIMER: (February 1, 2019) The views expressed in the translated editorial are solely the opinions of the Journal de Montréal and its editors.

Today, the French language populist newspaper Le Journal de Montreal published an article that states that it is “no coincidence” that Health Canada featured dried beans so prominently in the new Canada Food Guide; ‘certainly they are good for health’, but there is also an ‘obvious economic benefit and benefit to local agricultural interests’[1].

The pea arguments

[translation] This is not well known, but Canada is the major supplier of legumes (pulses) on the planet.  Between 35% and 40% of world production comes from here, essentially from the prairie  provinces. Quebec is participating by growing dry beans.”

Economic and Local Interest

The article states that in addition to the health benefits there are two reasons why legumes (pulses) feature so prominently in the new Canada Food Guide;

I – Economic interests – the first “because”

The Journal de Montreal article states that one of the additional reasons  legumes (pulses) were highlighted in the new Canada Food Guide was because Agriculture Canada had forecast a 20% decrease in production of legumes during 2019[1]. The reason for this decrease production is outlined below.

“Because of falling production”

II – benefit to local agriculture – the second “because”

The article also states that growing legumes benefits local agricultural interests[1] because;

“legumes contain bacteria that allow them to transfer nitrogen from the air to the ground and this nitrogen is needed for growth of vegetables.”

This means that by growing legumes one season, the soil becomes enriched with nitrogen which helps the growing of other food crops the following growing season.


BACKGROUND TO The FIRST “because”

Last March, the CBC reported that India, a top importer of Canadian chickpeas and lentils imposed a huge tariff on legumes which resulted in Canadian producers facing duties of 33% on lentils and 50% on desi chickpeas. The type that Canada produces are kabuli chickpeas, which have a slightly lower tariff of 40% [2]. These tariffs resulted in a decreased demand for Canadian legumes (pulses), as well as a price decline.

CBC also reported [3] that India’s imposed tariffs on pulses has sent “a huge ripple effect through the whole industry” as dried beans are a 1.1 billion dollar industry in Saskatchewan alone and India is it’s biggest customer[3].

“Farmers are calling on Prime Minister Justin Trudeau for help to make sure that business continues and to consider the importance of agriculture in Canada”[3].

New Canada Food Guide – free of influence?

The article in Le Journal de Montreal raises the question as to how much of the prominent inclusion of legumes (pulses) in the new Canada Food Guide has to do with their reported health benefits and how much may have been driven by industry or lobby groups influence on various levels of government due to decreased demand and resulting falling production.

UPDATE:(February 3, 2019): While it is evident from the CBC report[3] above that the pulse industry was exerting pressure on various levels of the Federal government to address decreased demand for its product, decreased legume production would have been factored into the design of the new Canada Food Guide as both (1) the role of legumes and plant-based dietary patterns on health and (2) food availability of legumes in light of decreased production would have necessarily been evaluated i.e. two of the four of the direct influences involved Dietary Guidance design. 

[see "Evidence Review for Dietary Guidance: Summary of results and implications for Canada's Food Guide, 2015" - available here) which on page 2 refers to the longer document "Colapinto CK, Ellis A, Faloon-Drew K, Lowell H Developing an evidence review cycle model for Canadian dietary guidance. Journal of Nutrition Education and Behavior. 2016;48:77-83)" that has Figure 2, below. 

This figure indicates that Food Availability of the Food Supply is one of the four direct influences in the development of Dietary Guidance.
Figure 2 Adapted Framework for Developing Dietary Guidance - Evidence Review Cycle Model for Canadian Dietary Guidance, from Colapinto et al 2016

While decreased legume production (i.e. food availability) would have been factored into the decision for Canadians to include more legumes in their diet for health benefits on the new Canada Food Guide, I can find no evidence that legume's benefit to agriculture was ever evaluated.

Some thoughts...

I think it is important to know what is said in the populist press about important issues such as this because a large segment of the population relies on such sources, as well as the internet for their news. Often times such stories are based on truth but leave what isn't said up to the audience (readers or listeners). Knowing the facts behind the story enables us to tease out conjecture from fact.

If you would like to learn more about what I do and how I can help, please have a look at the Services tab to learn more about the hourly consultations and packages that I offer. If you have questions about my services, please send me a note using the Contact Me form located on the tab above and I will reply as soon as I can.To your good health!

Joy

You can follow me at:

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Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Le Journal de Montreal – 29 January 2019 0600 https://www.journaldemontreal.com/2019/01/29/des-arguments-de-pois?
  2. CBC News – Pulse industry worries about precedent as India slaps 60% tariff on chickpeas – March 02, 2018 3:50 PM CT  https://www.cbc.ca/news/canada/saskatchewan/india-chickpea-tariff-pulse-industry-1.4559947
  3. CBC News – Prairie farmers want Canada’s trade dispute with India ‘straightened out’ – February 25, 2018 4:00 AM CT

 

The New Canada Food Guide – high carbohydrate & limited saturated fat

The new Canada Food Guide was officially released in Montreal today, January 22, 2019 and the suite of Food Guide resources includes;

  • Canada’s Dietary Guidelines for Health Professionals and Policy Makers
  • Food Guide Snapshot
  • Resources such as actionable advice, videos and recipes
  • Evidence including the Evidence Review for Dietary Guidance 2015 and the Food, Nutrients and Health: Interim Evidence Update 2018
Canada Food Guide “plate”

Canada Food Guide – directed towards healthy Canadians

According to Eating Well with Canada’s Food Guide – A Resource for Educators and Communicators the goal of Canada’s Food Guide is to ‘define and promote healthy eating for Canadians’ and to ‘translate the science of nutrition and health into a healthy eating pattern’. By definition, Canada’s Food Guide is directed towards a healthy Canadian population so they can meet their nutrient needs and reduce their risk of obesity and chronic diseases.

“By following Canada’s Food Guide, Canadians will be able to meet their nutrient needs and reduce their risk of obesity and chronic diseases such as type 2 diabetes, heart disease, certain types of cancer and osteoporosis.”

The New Canada Food Guide – no more rainbow

The familiar “rainbow” visual has been replaced with clear, simple photography illustrating food choices. In response to feedback from focus groups that the draft of the Guide focused too much on “how to eat” but didn’t provide adequate direction on “what to eat“, the final version clearly illustrates the proportion of vegetables and fruit, grains and protein foods to eat on a plate.

“Protein Foods”

As anticipated in the draft, the new Canada Food Guide dropped the Meat and Milk groups replacing it with an all-inclusive Protein food group which includes approximately equal amounts of animal-based and plant-based proteins.

Protein Foods Group

Animal-based proteins included beef, poultry, fish, egg and yogurt. Noticeably absent from animal-based proteins was cheese.

Plant-based proteins included legumes and pulses (beans and lentils), nuts and seeds and tofu.

Whole Grains

Whole Grains Food Group

The Whole Grain group is visually exemplified by whole grain bread, pasta, rice, wild rice, and quinoa and the link that relates to “whole grain foods” contains the following information;

  • Whole grain foods are good for you
  • Whole grain foods have important nutrients such as: fiber, vitamins and minerals
  • Whole grain foods are a healthier choice than refined grains because whole grain foods include all parts of the grain. Refined grains have some parts of the grain removed during processing.
  • Whole grain foods have more fibre than refined grains. Eating foods higher in fibre can help lower your risk of stroke, colon cancer, heart disease and type 2 diabetes
  • Make sure your choices are actually whole grain. Whole wheat and multi-grain foods may not be whole grain. Some foods may look like they are whole grain because of their colour, but they may not be. Read the ingredient list and choose foods that have the word “whole grain” followed by the name of the grain as one of the first ingredients like; whole grain oats, whole grain wheat. Whole wheat foods are not whole grain, but can still be a healthy choice as they contain fibre.
  • Use the nutrition facts table to compare the amount of fibre between products. Look at the % daily value to choose those with more fibre.

Vegetables and Fruit

Vegetable and Fruit Food Group

The new Guide illustrated that 1/2 the plate should be comprised of vegetables and fruit and the plate showed mostly non-starchy vegetables as broccoli, carrot, shredded peppers, cabbage, spinach and tomato, with a small amount of starchy vegetables as potato, yam and peas.

Fruit as blueberries, strawberry and apple was illustrated as a small proportion of the overall.

Beverage of Choice – water

The place setting showed a glass of water with the words “make water your drink of choice”; which indicates that fruit juice and pop (soft drinks) are not included as part of a recommended diet, but what about milk?

It is good that water is promoted as the beverage of choice, but why does the Guide doesn’t also illustrate a small glass of milk? The absence of milk in the new Guide seems odd.

Note: with both cheese and milk being limited in this new food guide, adequate calcium intake may be of concern; especially since vegetables that are high in calcium will have that calcium made unavailable to the body due to the high amounts of phytates, oxylates and lectins that are contained in the grains, nuts and seeds that are also in the diet.

Healthy Food Choices

The link for “healthy food choices” indicates;

  • Make it a habit to eat a variety of healthy foods each day.
  • Eat plenty of vegetables and fruits, whole grain foods and protein foods. Choose protein foods that come from plants more often.
  • Choose foods with healthy fats instead of saturated fat
    Limit highly processed foods. If you choose these foods, eat them less often and in small amounts.
  • Prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat
  • Choose healthier menu options when eating out
  • Make water your drink of choice
  • Replace sugary drinks with water
  • Use food labels
  • Be aware that food marketing can influence your choices

Eating Habits

The link for “healthy eating habits” indicates;

  • Healthy eating is more than the foods you eat. It is also about where, when, why and how you eat.
  • Be mindful of your eating habits
  • Take time to eat
  • Notice when you are hungry and when you are full
  • Cook more often
  • Plan what you eat
  • Involve others in planning and preparing meals
  • Enjoy your food
  • Culture and food tradition can be a part of healthy eating
  • Eat meal with others

Additional links on the web page include, Recipes, Tips and Resources.

First Impressions of the New Canada Food Guide

Overall, I think the new Canada Food Guide is visually clear, well illustrated and in terms of a communication tool is a huge improvement over its predecessor. It promotes a whole food diet with minimum processing, advises people to limit refined carbohydrates and sugary beverages as well as encourages people to cook their own food. It is neat, clean and appealing to look at and use.

I have two main concerns with respect to the Guide;

(1) the percentage of carbohydrate in the diet given the number of Canadians who are already metabolically unwell
(2) the focus on avoiding saturated fat as presumably a risk to health

Percentage of Carbohydrate in the Diet

At first glance, it would appear that the overall macronutrient distribution of the new Guide is ~10-15% of calories as protein, 15-20% as fat, leaving the remaining 65-75% of calories as carbohydrate (based on estimates by Dr. Dave Harper, visiting scientist at BC Cancer Research Institute, social media post). While no portions are set out in this new Guide, based on the carbohydrate (and protein) content of the legumes and pulses (beans, lentils) and nuts and seeds contained in the Protein food group, as well as their proportion of the food group, and the fact that they are encouraged to be eaten ‘more often’ than meat, the protein estimate seems accurate. As well, the carbohydrate content seems accurate based on the proportion of the Whole Grain group and carbohydrate-containing other foods relative to the proportion of other foods.

While this diet may be fine for those who are metabolically healthy, research indicates that as many as 88% of Americans [1] are already metabolically unwell, with presumably a large percentage of Canadians as well.

That is, only 12% have metabolic health defined as have levels of metabolic markers “consistent with a high level of health and low risk of impending cardiometabolic disease“. Metabolic Health is defined as [1];

  1. Waist Circumference: < 102 cm (40 inches) for men and 88 cm (34.5 inches) in women
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Glucose: < 5.5 mmol/L (100 mg/dL)
  5. HbA1c: < 5.7%
  6. Triglycerides: < 1.7 mmol/l (< 150 mg/dL)
  7. HDL cholesterol: ≥ 1.00 mmol/L (≥40 mg/dL) in men and ≥ 1.30 mmol/L (50 mg/dl) in women

When looking at only 3 of the above 7 factors (waist circumference, blood glucose levels and blood pressure) more than 50% in this study were considered metabolically unhealthy [1]. Given the slightly lower rates of obesity in Canada (1 in 4) as in the United States (1 in 3), presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant.

This would indicate that for a large percentage of Canadians that are  metabolically unwell, a diet that provides provides ~325-375 g of carbohydrate per day (based on a 2000 kcal per day diet) is not going to adequately address the underlying cause. While there is evidence that a high complex carbohydrate diet with very low fat and moderately-low protein intake (called a “whole food plant based” / WFPB diet) will improve weight and some markers of metabolic health, there is also evidence that a WFPB diet doesn’t work as well at improvements in body weight and metabolic markers as a low carbohydrate higher protein and fat (LCHF) diet. This will be addressed in a future article.

The purpose Canada’s Food Guide is to provide guidance for healthy Canadians so in actuality, this diet may only be appropriate for ~15% of adults.

Saturated Fat

The indication to “choose foods with healthy fats instead of saturated fat” and to “prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat” sends the message that saturated fat is unhealthy.

It is well-known that saturated fat raises LDL-cholesterol however it must be specified which type of LDL-cholesterol increases. There are small, dense LDL cholesterol which easily penetrates the artery wall and which are associated with heart disease [2,3,4,5] and large, fluffy LDL cholesterol      which are not [6,7].

The long-standing and apparently ongoing recommendation to limit saturated fat is based on it resulting in an increase in overall LDL-cholesterol and not on evidence that increased saturated fat in the diet results in heart disease.

What do recent studies show?

Eight recent meta-analysis and systemic reviews which reviewed evidence from randomized control trials (RCT) that had been conducted between 2009-2017 did not find an association between saturated fat intake and the risk of heart disease [8-15] and the results of the largest and most global epidemiological study published in December 2017 in The Lancet [16] found that those who ate the largest amount of saturated fats had significantly reduced rates of mortality and that low consumption (6-7% of calories) of saturated fat was associated with increased risk of stroke.

UPDATE: There are 44 randomized controlled trials (RCTs) of drug or dietary interventions to lower total LDL-cholesterol that showed no benefit on death rates. (Reference:  DuBroff R. Cholesterol paradox: a correlate does not a surrogate make. Evid Based Med 2017;22(1):15–9.

Canadians are being encouraged to limit foods that are sources of saturated fat. In fact, cheese and milk aren’t even illustrated as foods to regularly include.

Where is the evidence that eating foods with saturated fat is dangerous to health — not simply that it raises overall LDL-cholesterol? I believe that for Canadians to be advised to limit cheese and milk which are excellent sources of protein and dietary calcium and to limit other foods high in saturated fat necessitates more than proxy measurements of higher total LDL-cholesterol.

Dr. Zoe Harcombe a UK based nutrition with a PhD in public health nutrition wrote an article this time last year about saturated fat [17] which is helpful to refer to here.

People have the idea that meat has saturated fat and foods like nuts and olives have unsaturated fats, but Dr. Harcombe points out that;

“All foods that contain fat contain all three fats – saturated, monounsaturated and polyunsaturated – there are no exceptions.”

This article explains may explain why cheese was not included as part of the visual representation of animal-based Protein Foods in the new Guide and why milk was not visually represented because “the only food group that contains more saturated than unsaturated fat is dairy”.

A link off the main page of the new Canada Food Guide explains how to “limit the amount of foods containing saturated fat” such as;

Limit foods that contain saturated fat

Limit the amount of foods containing saturated fat, such as:

cream

higher fat meats
.
.
.
cheeses and foods containing a lot of cheese

Are Canadians being encouraged to avoid cheese and milk because they are high in saturated fat? Where is the evidence that saturated fat contributes to heart disease?

There is proxy data that saturated fat raises total LDL-cholesterol, but not that saturated fat causes heart disease.  In fact, a review of the recently literature finds that it does not (see above).

If saturated fat actually puts one’s health at risk, then Canadians should be warned that olive oil has 7 times the amount of saturated fat as the sirloin steak illustrated below and the mackerel has 1- 1/2 times the saturated fat as the sirloin steak [16] yet the new Guide recommends that Canadian’s choose foods with “healthy fats” such as fatty fish including mackerel and to use “healthy fats” such as olive oil.

from Reference #17

Final thoughts…

In generations past, Canada food Guide helped Canadians make food choices in order to achieve adequate nutrition for themselves and their families, especially in the early years after WWII.  With current rates of overweight, obesity, Type 2 Diabetes and other forms of metabolic dysregulation, I wonder how few this beautiful new Guide is appropriate for.

If you would like to learn more about how I can help you or a family member achieve and maintain a healthy body weight and to achieve metabolic health, please send me a note using the Contact Me form located on the tab above.

To our good health!

Joy

In the following post, I validate the average amount of carbohydrate in this new Canada Food Guide.

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Copyright ©2019 The LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  2. Tribble DL, Holl LG, Wood PD, et al. Variations in oxidative susceptibility among six low density lipoprotein subfractions of differing density and particle size. Atherosclerosis 1992;93:189–99
  3. Gardner CD, Fortmann SP, Krauss RM, Association of Small Low-Density Lipoprotein Particles With the Incidence of Coronary Artery Disease in Men and Women, JAMA. 1996;276(11):875-881
  4. Lamarche B, Tchernof A, Moorjani S, et al, Small, Dense Low-Density Lipoprotein Particles as a Predictor of the Risk of Ischemic Heart Disease in Men, 
  5. Packard C, Caslake M, Shepherd J. The role of small, dense low density lipoprotein (LDL): a new look, Int J of Cardiology,  Volume 74, Supplement 1, 30 June 2000, Pages S17-S22
  6. Genest JJ, Blijlevens E, McNamara JR, Low density lipoprotein particle size and coronary artery disease, Arteriosclerosis, Thrombosis, and Vascular Biology. 1992;12:187-195
  7. Siri-Tarino PW, Sun Q, Hu FB, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 502–509
  8. Skeaff CM, PhD, Professor, Dept. of Human Nutrition, the University of Otago, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence From Prospective Cohort and Randomised Controlled Trials, Annals of Nutrition and Metabolism, 2009;55(1-3):173-201
  9. Hooper L, Summerbell CD, Thompson R, Reduced or modified dietary fat for preventing cardiovascular disease, 2012 Cochrane Database Syst Rev. 2012 May 16;(5)
  10. Chowdhury R, Warnakula S, Kunutsor S et al, Association of Dietary, Circulating, and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis, Ann Intern Med. 2014 Mar 18;160(6):398-406
  11. Schwingshackl L, Hoffmann G Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and meta-regression BMJ Open 2014;4
  12. Hooper L, Martin N, Abdelhamid A et al, Reduction in saturated fat intake for cardiovascular disease, Cochrane Database Syst Rev. 2015 Jun 10;(6)
  13. Harcombe Z, Baker JS, Davies B, Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis, Br J Sports Med. 2017 Dec;51(24):1743-1749
  14. Ramsden CE, Zamora D, Majchrzak-Hong S, et al, Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73), BMJ 2016; 353
  15. Hamley S, The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials, Nutrition Journal 2017 16:30
  16. Dehghan M, Mente A, Zhang X et al, The PURE Study – Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
  17. Harcombe  Z, Saturated Fat,  http://www.zoeharcombe.com/2018/01/saturated-fat/

EAT-Lancet Diet – inadequate protein for older adults

We’ve come to expect that as people age they will gain more fat, loose bone mass and have decreased muscle strength which in time leads to difficulty in them getting around on their own, a greater risk of falls and eventually to physical disability. We commonly see older people with spindly little legs and bony arms and we think of this as ‘normal’. It is common in the United States and Canada, but this is not ‘normal’.

Sarcopenia is the visible loss of muscle mass and strength that has become associated with aging here, but what we see as ‘common’ here in North America is not ‘normal’ in other parts of the world where seniors in many parts of Asia and Africa are often active well into their older years and don’t have the spindly legs and bony arms of those here.

Here in North America, we celebrate ‘active’ seniors by posting photos of them in the media sitting in chairs and lifting light weights — when people their age in other parts of the world continue to raise crops, tend their grandchildren and cook meals for their extended family, even gathering fuel and water to do so.

The physical deterioration that we associate with aging here doesn’t  develop suddenly, but takes place over an extended period of time and is brought on by poor dietary and lifestyle practices in early middle age –  including less than optimal protein intake and insufficient weight bearing activity from being inactive.

Protein Requirement in Older Adults

The Recommended Dietary Allowance (RDA) for protein is set at 0.8 g protein/kg per day is not the ideal amount that people should take in, but the minimum quantity of protein that needs to be eaten each day to prevent deficiency. Protein researchers propose that while sufficient to prevent deficiency, this amount is insufficient to promote optimal health as people age[1].

There have been several position statements issued by those that work with an aging population indicating that protein intake between 1.0 and 1.5 g protein / kg per day may provide optimal health benefits during aging [2,3]. For an normal-sized older woman of my size, that requires ~65-95 g of high quality bioavailable protein per day and for a lean older man of ~185 lbs (85 kg) that would require between 85 – 125 g of high quality bio-available protein per day

High bioavailability proteins are optimal to preserve the lean muscle tissue and function in aging adults and animal-based proteins such as meat and poultry are not biologically equivalent to plant-based proteins such as beans and lentils in terms of the essential amino acids they provide.

Animal-based protein have high bioavailability and are unequaled by any plant-based proteins. Bioavailability has to do with how much of the nutrients in a given food are available for usage by the human body and in the case of protein, bioavailability  has to do with the type and relative amounts of amino acids present in a proteinAnimal proteins (1) contain all of the essential amino acids in sufficient quantities.

Anti-nutrients such as phytates, oxylates and lectins are present in plant-based protein sources and interfere with the bioavailability of various micronutrients.

The recommendations above for older adults to eat 1.0 – 1.5 g protein / kg per day distributed evening over three meals would be on average ~30-40g of animal-based protein at each meal to provide for optimal muscle protein synthesis to prevent sarcopenia as people age.  In an aging population, this maintenance of muscle mass as people age is critical to consider.

The Eat-Lancet Diet

Dr. Zoe Harcombe, a UK based nutrition with a PhD in public health nutrition analyzed the “Healthy Reference Diet” from Table 1 of the Eat-Lancet report using the USDA (United States Department of Agriculture) all-food database and found that in terms of macronutrients, it had only 90g  Protein per day (14% of daily calories) which is below the 100g – 120 g per day that is consider optimal for older adults to maintain their lean muscle mass and as importantly, most of that protein is as low bioavailable plant-based proteins.

The Eat-Lancet Diet recommends only;

  • 1 egg per week
  • 1/2 an ounce of meat per day (equivalent to a thin slice of shaved meat)
  • an ounce of fish or chicken per day (equivalent to 1 sardine)
  • and 1 glass of milk

This is not an optimal diet to prevent sarcopenia in adults as they age.

A diet that puts seniors at significant risk of muscle wasting contributes to the loss of quality of life, significant costs to the healthcare system, as well significant cost and stress to individual families that need to care for immobile seniors.

This diet may be beneficial for those living with consistent under-nutrition (malnutrition) but this diet is anything but optimal for healthy, independent aging for the seniors of the US and Canada.

As mentioned in the previous article, the EAT-Lancet Diet also provides way too much carbohydrate intake for the 88% of Americans (and presumably a similar percentage of Canadians) who are metabolically unwell.

Final Thoughts…

For reasons mentioned above, the EAT-Lancet diet is not optimal for health for mature adults or older adults and as mentioned in the previous article, has way too high a carbohydrate intake for the vast majority of people who are already metabolically unwell.

If you would like to learn more about eating an optimal diet to support an active, healthy older age, please send me a note using the Contact Me form, above.

To your good health!

Joy

You can follow me at:

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Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Volpi E, Campbell WW, Dwyer JT, et al. Is the optimal level of protein intake for older adults greater than the recommended dietary allowance? J Gerontol A Biol Sci Med Sci. 2013 Jun;68(6):677-81
  2. Fielding RA, Vellas B, Evans WJ, Bhasin S, et al, Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56
  3. Bauer J1, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
  4. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/

The New EAT Lancet Diet – a healthy & sustainable diet for whom?

A new report released on January 16, 2019 by the EAT-Lancet Commission on Food, Planet and Health sets out what it calls a “healthy and sustainable diet” [1] for the whole world. The EAT-Lancet report proposes what it calls the “Planetary Health Diet“; a largely plant-based diet which aims to address the simultaneous global problems of malnutrition (under-nutrition) and over-nutrition; specifically that “over 820 million people continue to go hungry every day, 150 million children suffer from long-term hunger that impairs their growth and development, and 50 million children are acutely hungry due to insufficient access to food” and that at the same time “over 2 billion adults are overweight and obese”[2]. The “Planetary Health Diet” intends address both under-nutrition and over-nutrition simultaneously by promoting a 2500 kcal per day diet that focuses on high consumption of carbohydrate-based grains, vegetables, fruit, legumes (pulses and lentils) — while significantly limiting meat and dairy. This sounds a lot like the proposed draft of the new Canada Food Guide (which you can read more about here).

The Planetary Health Diet

The Planetary Health Diet – aka the EAT-Lancet Diet [4]
Here is the food per day that can be eaten per adult on the “Planetary Health Diet“;

  1. Nuts: 50 g (1 -3/4 ounces) /day
  2. Legumes (pulses, lentils, beans): 75 g (2-1/2 oz) /day
  3. Fish: 28 g (less than an ounce) / day
  4. Eggs: 13 g / day (~ 1 egg per week)
  5. Meat: 14 g (1/2 an ounce) / day / Chicken: 29 g (1 ounce) / day
  6. Carbohydrate: whole grain bread and rice, 232 g carbohydrate per day and 50 g / day of starchy vegetables like potato and yam
  7. Dairy: 250 g (the equivalent of one 8 oz. glass of milk)
  8. Vegetables: 300 g (10.5 ounces) of non-starchy vegetables and 200 g (almost 1/2 a pound) of fruit per day
  9. Other: 31 g of sugar (1 ounce), ~50 g cooking oil
On this diet, you can have twice the amount of sugar as meat or egg, and the same amount of sugar as poultry and fish.

While is is understandable how the above diet may address the problems of under-nutrition in much of the world’s population, what about the effect of such a diet on the average American or Canadian — when 1 in 3 Americans[5] and 1 in 4 Canadians is overweight or obese[6]?

Vast Majority (88%) of Americans are Metabolically Unhealthy

A study published in November 2018 in Metabolic Syndrome and Related Disorders reported that 88% of Americans are already metabolically unhealthy[3]. That is, only 12% have metabolic health defined as have levels of metabolic markers “consistent with a high level of health and low risk of impending cardiometabolic disease“. Metabolic Health is defined as [3];

  1. Waist Circumference: < 102 cm (40 inches) for men and 88 cm (34.5 inches) in women
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Glucose: < 5.5 mmol/L (100 mg/dL)
  5. HbA1c: < 5.7%
  6. Triglycerides: < 1.7 mmol/l (< 150 mg/dL)
  7. HDL cholesterol: ≥ 1.00 mmol/L (≥40 mg/dL) in men and ≥ 1.30 mmol/L (50 mg/dl) in women

When looking at only 3 of the above 7 factors (waist circumference, blood glucose levels and blood pressure) more than <50% of Americans were considered metabolically unhealthy [3]. Given the slightly lower rates of obesity in Canada[6] as in the United States[5], presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant. As well, it was not only those who were overweight or obese who were metabolically unhealthy;

“Even when WC (waist circumference) was excluded from the definition, only one-third of the normal weight adults enjoyed optimal metabolic health.”

For the 12% of people who are metabolically healthy, a plant-based low glycemic index diet is not problematic, but it's a concern to recommend to the other 88% to eat that way — especially if they are insulin resistant or have Type 2 Diabetes.

Is the “Planetary Health Diet” an advisable diet for the average American or Canadian adult who is already metabolically unhealthy? To answer this question, let’s look closer at the macronutrient and micronutrient content of this diet. Below is the “healthy reference diet” from page 5 of the report [7], which is based on an average intake of 2500 kcal per day;

Table 1 – Healthy reference diet, with possible ranges, for an intake of 2500 kcal/day (from Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems)

Nutritional Deficiency of the Eat-Lancet Diet

Dr. Zoe Harcombe a UK based nutrition with a PhD in public health nutrition analyzed the above “Healthy Reference Diet” from Table 1 of the Eat-Lancet report using the USDA (United States Department of Agriculture) all-food database and found that in terms of macronutrients, it had [8]; Protein: 90 g (14% of daily calories) Fat: 100 g (35% of daily calories) Carbohydrate: 329 g (51% of daily calories) Dr. Harcombe also reported that in terms of micronutrients, the diet was deficient in retinol (providing only 17% of the recommended amount), Vitamin D (providing only 5% of the recommended amount), Sodium (providing only 22% of the recommended amount), Potassium (providing only 67% of the recommended amount), Calcium (providing only 55% of the recommended amount), Iron  (providing only 88% of the recommended amount, but mostly as much lower bio-available non-heme iron, from plant-based sources), as well as inadequate amounts of Vitamin K (as the most bio-available comes from animal-based sources).

High Carbohydrate Content

The “Planetary Health Diet” contains on average approximately 329 g of carbohydrate per day which is of significant concern — especially in light of the extremely high rates of overweight and obesity in both the United States and Canada, as well as the metabolic diseases that go along with those, including Type 2 Diabetes (T2D), cardiovascular disease, hypertension, and abnormal triglycerides. Since 1977, Canada Food Guide has recommended that Canadians consume 55-60% of daily calories as carbohydrate and the Dietary Goals for the United States recommending that carbohydrates are 55-60% of daily calories and in 2015, Canada Food Guide increased the amount of daily carbohydrate intake to 45-65% of daily calories as carbohydrate. What has happened to the rates of overweight and obesity, as well as diabetes from 1977 until the present? In the early 1970s, only ~8% of men and ~12% of women in Canada were obese and now almost 22% of men and 19% of women are obese. As mentioned above, 1 in 4 in Canada is obese and 1 in 3 in the US is and with those, Type 2 Diabetes as well as the metabolic diseases mentioned above.

Final Thoughts…

The Dietary Guidelines of both Canada and the US have spent the last 40 years promoting a high carbohydrate diet that has provided adults with between 300 g and 400 g of carbohydrate per day (based on a 2500 kcal / day diet). EAT-Lancet’s “Planetary Health Diet” may seem to be good for the planet, and for those facing under-nutrition in many parts of the world, but with 88% of Americans already metabolically unhealthy (and presumably the majority of Canadians as well), this diet which provides 300 g of carbohydrate per day is going to do nothing to address the high rates of overweight and obesity and metabolic disease that is rampant in North America.

If you would like to learn more about a low carbohydrate diet for weight loss or for putting the symptoms of Type 2 Diabetes and associated metabolic diseases into remission, please send me a note using the Contact Me form.

To our good health!

Joy

If you would like to learn why this diet provides inadequate protein for older adults and seniors, please click here.

You can follow me at:

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https://www.instagram.com/lchf_rd

 

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. The EAT-Lancet Commission on Food, Planet and Health,  https://eatforum.org/eat-lancet-commission/
  2. The EAT-Lancet Commission on Food, Planet and Health – EAT-Lancet Commission Brief for Healthcare Professionals,  https://eatforum.org/lancet-commission/healthcare-professionals/
  3. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  4. BBC News, A bit of Meat, a lot of veg – the flexitarian diet to feed 10 billion, James Gallagher, 17 January 2019, https://www.bbc.com/news/health-46865204
  5. State of Obesity, Adult Obesity in the United States, https://stateofobesity.org/adult-obesity/
  6. Statistics Canada, Health at a Glance, Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias,  https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/11922-eng.htm
  7. Willet W, Rockstrom J, Loken B, et al, Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems, The Lancet Commissions, http://dx.doi.org/10.1016/ S0140-6736(18)31788-4
  8. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/

What is a Mediterranean Style Diet?

The recently released 2018 Clinical Practice Guidelines (CPG) Guidelines of Diabetes Canada recommend that those with Diabetes continue to eat 45% to 65% of their daily calories as carbohydrate, 10% to 35% of their daily calories as protein and only 20% to 35% of their daily calories, yet affirm that there is “evidence to support a number of other macronutrient-, food- and dietary pattern-based approaches” and that “evidence is limited for the rigid adherence to any single dietary approach”[1] .

One of the dietary patterns they recommend is a “Mediterranean-style dietary pattern” in order to “reduce major cardiovascular events and improve glycemic (blood sugar) control.”

So what is a “Mediterranean-style dietary pattern“?

According to the Clinical Practice Guidelines,

A “Mediterranean diet” primarily refers to a plant-based diet first described in the 1960s. General features include a high consumption of fruits, vegetables, legumes, nuts, seeds, cereals and whole grains; moderate-to-high consumption of olive oil (as the principal source of fat); low to moderate consumption of dairy products, fish and poultry; and low consumption of red meat, as well as low to moderate consumption of wine, mainly during meals”

Countries with coastlines on the Mediterranean Sea include Albania, Algeria, Bosnia and Herzegovina, Croatia, Cyprus, Egypt, France, Greece, Israel, Italy, Lebanon, Libya, Malta, Morocco, Monaco, Montenegro, Slovenia, Spain, Syria, Tunisia and Turkey and the diets of these countries vary considerably, so there isn’t only ONE “Mediterranean Diet“.

What is the Mediterranean Diet that the Clinical Practice Guidelines are referring to?

It would seem that they are referring to dietary intake based of southern Italy from the 1960s from when rates of chronic disease were reported to be amongst the lowest in the world and adult life expectancy was reported to be amongst the highest. That is, the health benefits of “The Mediterranean Diet” came out of Ancel Keys’ Six Country Study (1953) and later his Seven Countries Study (1970).  More on that below.

One of the academic papers that the Guidelines cites as the basis for a “Mediterranean diet” makes the direct link to Ancel Keys clear;

“Ecologic evidence suggesting beneficial health effects of the Mediterranean diet has emerged from the classic studies of
Keys.” [2]

In 1953, Ancel Keys published the results of his “Six Countries Study“[3], where it is said he demonstrated that there was an association between dietary fat as a percentage of daily calories and death from degenerative heart disease.

Four years later, in 1957, Yerushalamy published a paper with data from 22 countries [4], which showed a much weaker relationship between dietary fat and death by coronary heart disease than was suggested by Keys’s six country data (see below).

from [3].Keys, A. Atherosclerosis: a problem in newer public health. J. Mt. Sinai Hosp. N. Y.20, 118–139 (1953).

from [4] Yerushalmy J, Hilleboe HE. Fat in the diet and mortality from heart disease. A methodologic note. NY State J Med 1957;57:2343–54

Nevertheless, in 1970, Keys went on to publish his Seven Countries Study in which he maintained that there was an associative relationship between increased dietary saturated fat and Coronary Heart Disease – ignoring the data presented in Yerushalamy’s 1957 study and failing to study countries such as France, in which the relationship did not hold.

In Keys’ paper published in 1989 [5] which was based on food consumption patterns in the 1960s in the seven countries, he found that the average consumption of animal foods (with the exception of fish) was positively associated with 25 year Coronary Heart Disease deaths rates and the average intake of saturated fat was strongly related to 10 and 25 year CHD mortality rates. Keys published this study 32 years after Yerushalamy’s 1957 paper which showed a significantly weaker relationship, yet it seems that people only remember Key’s data.

Countries with coastlines on the Mediterranean Sea on which there was known dietary and disease data in 1957 and that Keys later ignored in 1970 included France (labelled #8 on Yerushalamy’s graph above) and Israel (labelled #11). France is known for the “French paradox” (a term which came about in the 1980s) because of their relatively low incidence of coronary heart disease (CHD) while having a diet relatively rich in saturated fats. According to a 2004 paper about the French Paradox, there was diet and disease data available from the French population that was carried out in 1986–87 and which demonstrated that the saturated fat intake of the French was 15% of the total energy intake, yet such a high consumption of saturated fatty acids was not associated with high Coronary Heart Disease incidence in France [6]. Nevertheless, Keys published his 1989 study [5] ignoring the French dietary and disease data that was available from 1986-1987 [6]. Was it because it didn’t fit his hypothesis?

The diet of the French in the 1960's was every bit a "Mediterranean Diet" as that of southern Italy, but since Ancel Keys ignored (or did not study) the French data in the 1960s, that "Mediterranean Diet" remains ignored in the guidelines of today.

According to the French Paradox paper, high saturated fat intakes combined with low Coronary Heart Disease rates were also observed in other Mediterranean countries, including Spain and that rates in other non-Mediterranean Europeans countries such as Germany, Belgium are similar [6].

Perhaps then, a ‘true’ Mediterranean Diet which is protective of Coronary Heart Disease ought not to be defined as being largely “plant-based” and “low in consumption of red meat and dairy” – which the French diet clearly is not, but rather should focus on being a diet high in consumption of specific types of vegetables and fruit, nuts and seeds, abundant in the use of olive oil and that includes regular consumption of wine with meals.

As outlined in a recent article, eight recent meta-analysis and systemic reviews which reviewed evidence from randomized control trials that had been conducted between 2009-2017 did not find an association between saturated fat intake and the risk of heart disease. As well, recently published results from the Prospective Urban and Rural Epidemiological (PURE) Study, the largest and most global epidemiological study carried out to date and published in the Lancet in December 2017 found that those who ate the largest amount of saturated fats had significantly reduced rates of mortality (death) and that low consumption of saturated fat (6-7% of calories) was actually associated with increased risk of stroke.

Also as described in a recent article, a study published at the end of March 2017 in Nutrients and which examined health and nutrition data from 158 countries worldwide found that total fat and animal fat consumption were least associated with the risk of cardiovascular disease, and that high carbohydrate consumption, particularly as cereals and wheat was most associated with the risk of cardiovascular disease – with both of these relationships holding up regardless of a nation’s average national income.

Final Thoughts…

The 2018 Clinical Practice Guidelines continue to recommend the health benefits of a “Mediterranean style diet” defined based on the 60-year-old-data of Ancel Keys’ Six Countries Study / 50 year old Seven Countries Study- when we now know that Keys excluded data that was available from countries including France, which did not fit his hypothesis.

Given that there seems to be increasing evidence that Keys’ Diet-Heart Hypothesis (the belief that dietary saturated fat causes heart disease) has been significantly challenged by newer data, is it not time to study the factors in the diet of this region that ARE protective against cardiovascular disease, and to redefine a Mediterranean diet in these terms?

Would you like to have a Meal Plan that emphasizes the foods of this region, including meat and cheese, fish and seafood, vegetables and fruit, nuts and seeds, olive oil and wine and which may play a protective role in heart heath?

Please send me a note using the Contact Me form located on the tab above, and I will reply as soon as possible.

To our good health!

Joy

If you would like to read well-researched, credible “Science Made Simple”  articles on the use of a low carb or ketogenic diet for weight loss, as well as to significantly improve and even reverse the symptoms of Type 2 Diabetes, high cholesterol and other metabolic-related symptoms, please  click here.

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References

  1. Sievenpiper JL, Chan CB, Dwortatzek PD, Freeze C et al, Nutrition Therapy – 2018 Clinical Practice Guidelines, Canadian Journal of Diabetes 42 (2018) S64–S79 http://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf
  2. Trichopoulou A, Costacou T, Bamia C et al, Adherence to a Mediterranean Diet and Survival in a Greek Population, N Engl J Med 2003;348:2599-608.
  3. Keys, A. Atherosclerosis: a problem in newer public health. J. Mt. Sinai Hosp. N. Y.20, 118–139 (1953).
  4. Yerushalmy J, Hilleboe HE. Fat in the diet and mortality from heart disease. A methodologic note. NY State J Med 1957;57:2343–54
  5. Kromhout D, Keys A, Aravanis C, Buzina R et al, Food consumption patterns in the 1960s in seven countries. Am J Clin Nutr. 1989 May; 49(5):889-94.
  6. Ferrières J. The French paradox: lessons for other countries. Heart. 2004;90(1):107-111.

Copyright ©2018  The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.) 

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Low Carb or Keto – what can you eat?

Most criticism of a low carb lifestyle or ketogenic diet centers around a few common misconceptions including that such a lifestyle is “restrictive”, “imbalanced”, or that it’s “not sustainable”. This article addresses all three.

Firstly, as explained in an earlier post there isn’t a single “low carb” diet but basically 3 styles;

(1) low carb high protein
(2) low carb high fat approach
(3) higher protein lower fat intake during weight loss, then a moderate protein high fat intake during weight maintenance

What makes a low carb diet keto” is the amount of carbohydrate that is eaten.

There are different types of therapeutic ketogenic diets which have different clinical applications, including use in epilepsy and seizure disorder, specific types of cancer, Polycystic Ovarian Syndrome (PCOS), weight loss and improving insulin sensitivity and in each case, the ratio of protein to fat is specific to the condition (and in cases of weight loss and improving insulin sensitivity, to the individual).

While our bodies have an absolute requirement for essential amino acids, and essential fatty acids, as covered in detail in an earlier article, according to the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) there is no essential need for dietary carbohydrate provided that “adequate amounts of protein and fat are consumed”.

That is, a low carb or ketogenic diet can be ‘complete’ as long as it supplies adequate amounts of protein (with all essential amino acids) and fat (with the essential fatty acids) and also provides the other nutrients the body requires (such as vitamins and minerals).

This is where I can help. I'll design a nutritionally adequate Meal Plan specifically for you, in light of any clinical conditions you may have and factoring in your goals in choosing to eat this way.

Let me address the common (but unfounded) misconceptions that a low carb or ketogenic diet is “restrictive”, “imbalanced” or “not sustainable”.

A Low Carb or Keto Diet is “restrictive”, “imbalanced” or “not sustainable”

Usually, when people make comments like these, they have absolutely no idea that there are different types of low carb and keto diets. Ketogenic diets used in epilepsy and seizure disorder are very specific, as are ketogenic diets used for those with specific types of cancer. Ketogenic diets used to target insulin resistance associated with Type 2 Diabetes or pre-Diabetes are different again.

Foods and ratios of foods eaten when following a low carb diet targeting insulin resistance based on Dr. Jason Fung’s approach will differ somewhat from a low carb diet based on Dr. Eric Westman’s approach. A low carb diet based on Dr. Stephen Phinney and Dr. Jeff Volek’s approach will be different during the weight loss phase than during weight maintenance. As well, some low carb diets target protein and others target fat. Some promote unrestricted saturated fat in all forms, including bacon and cream, while others don’t. For example Dr. Fung’s approach does not limit eggs, cream and bacon and for weight loss, Dr. Westman’s approach does.

Low Carb Food Categories (based on a diagram from Dr. Ted Naiman)

In my practice, I focus on whole, unprocessed foods that are naturally low in carbohydrates and that come from a wide range of food categories, including non-starchy vegetables, plant fats, low sugar fruit, meat fish poultry and seafood, and animal fat.

I encourage people to eat the fat naturally found in the flesh of animal protein, but to trim meat of extraneous visible fat.

If people enjoy eating bacon from time to time, I’d encourage them to obtain one that is naturally cured and smoked and to eat it on occasion rather than daily.

From my perspective, it makes no sense for someone seeking weight loss to ‘add fat’ to foods for the sake of adding fat (e.g. ‘bulletproof’ coffee or ‘fat bombs’).  If people want to have a bit of cream in their coffee or a touch of butter on their asparagus there’s no reason why not, as there is nothing intrinsically ‘dangerous’ about fat, even saturated fat (more on this in upcoming blogs!). However from my perspective, adding coconut oil and butter to coffee for the sake of “adding fat” makes no sense, even for those following a “ketogenic” diet. I encourage folks to pursue health, not ketones.

Note: There are very few physiological conditions that require very high fat intake such as specialized diets for epilepsy or seizure disorder or for specific types of cancer as an adjunct to treatment.

To address the misconceptions that a low carb or ketogenic diet is restrictive, imbalanced or in any way unsustainable, below are some photos of types of foods that I prepare and eat. Everybody has different types of foods that they enjoy, these are simply some of mine.

Keep in mind that in some photos, only the main course is shown not the large salad or side of cooked vegetables which almost always accompanies it. As well, many of the servings shown are of one of my young adult son’s plates, rather than mine (my serving sizes are different because my nutritional needs are different).

I am showing these photos to dispel the myth that eating a low carb diet is in any way “restrictive“, “imbalanced” or “not sustainable” and I hope they give you some ideas of the wide range of whole, delicious food that is available to be enjoyed when pursuing a low carb or keto lifestyle.


Shakshuka is weekend breakfast or brunch food, that I usually serve with a huge mixed green salad or cucumber and tomato salad.

Shakshuka for three
individual serving of shakshuka

Another favourite on the weekend is Vanilla Bean Pancakes – which one of my young adult sons loves to smother in butter (too much butter for me!). That day, he had poached eggs on the side and a mixed green salad with pumpkin seeds and pomegranate arils on top, drizzled with cold-pressed olive oil.

One of my young adult son’s helping of Vanilla Bean pancakes and butter
a close up of a Vanilla Bean pancake

This is one of my favourite breakfast or brunch salads:

Greek salad with mini marzano tomatoes, mini cukes, goat feta and kalamata olives with a drizzle of cold pressed olive oil, rubbed oregano and fresh lemon

Below is a totally decadent plate that I made this past Sunday from the other half of my rib steak that I cooked the night previously (way too much meat for me!!), that I sliced thinly and warmed with stir fried asparagus, roasted peppers (also from the previous night’s supper) and a few thin slices of melted brie on top. This was shared between two for brunch, and served along with a mixed green salad.

Brunch plate made with leftover steak, roasted peppers and asparagus, with melted brie
BBQ’d burgers on a lettuce bun with grilled asparagus and a small side salad

Here’s how we eat “burgers” for dinner.

 

 

 

…and a close up of one of my son’s plates:

BBQ’d cheese burgers served on a lettuce bun

The burgers look bigger than they are, because they are served on a smaller diameter “lunch” plate, rather than a “dinner” plate. The burgers in this case were served with a large mixed green salad, with a few raspberries on top, a light sprinkling of roasted pumpkin seeds along with a drizzle of cold- pressed olive oil.

Below is one of my son’s plates of lamb souvlaki that I also made this past weekend, and served with homemade tzatiki, grilled asparagus and a small Greek salad on the side (my plate had less lamb and a smaller piece of feta and more asparagus – again, because my nutritional needs are different).

a son’s plate of lamb souvlaki with homemade tzatiki, grilled asparagus and small Greek salad

…and finally, this is a popular weekend Middle Eastern style brunch in warmer weather:

Homemade Maza for weekend brunch

Want “noodles”? Sure!  See the “Recipe” tab for details.

low carb broad noodles

These can be cut (or bought pre-cut) in thinner slices like linguine and are wonderful topped with spaghetti sauce or pesto.

Eating low carb or keto need not involve this much cooking, either! One can make a simple piece of grilled, broiled or pan-fried fish or chicken, some cooked veggies in the microwave and/or a salad.  I happen to enjoy cooking (and my sons enjoy eating!) so this is something I do to relax.

Whether the meals are simple with little cooking required or elaborate, there is nothing “restrictive” about eating low carb.

As for eating this way being “imbalanced“, someone would be hard-pressed to demonstrate that eating this way doesn’t provide adequate nutrients. There is cheese and other dairy, nuts, seeds, fruit, vegetables and a wide variety of meat, fish and poultry. The diet provides all essential amino acids, essential fatty acids and ample vitamin and minerals – certainly no less than the average Canadian diet provides!

As for eating this way being “not sustainable“, what is not sustainable about eating fresh, healthy, whole foods that can be eaten with a minimum of preparation or as elaborate as one’s imagination allows?

I know of people that have been eating this way for 15 or 20 years and I personally have been eating this way for just over a year now (see “A Dietitian’s Journey” tab) and there is nothing that I miss!

If I want something, I make it!

When it was blustery out, I wanted to make “Shepherd’s Pie”, so I made it, substituting cut up green and waxed beans with cubed carrot for the usual vegetable medley and topping with mashed cauliflower, instead of mashed potato.

low carb Shepherd’s Pie

Another time, I felt like lasagna so I made it with thinly sliced Chinese eggplant in place of pasta and it was delicious!

low carb lasagna

Oh and bread? No worries!

One of my son’s wanted a “grilled cheese” and so I made him this.

low carb grilled cheese

What if you want a kaiser bun for a sandwich, or a hamburger bun? No problem (see “Recipes” tab).

Low carb kaiser bun sandwich
freshly baked low carb hamburger buns

Crispy, yeasty pizza? Sure! Yes, the full recipe is available on the “Recipe” tab.

crispy, yeast pizza

While “keto pizza” is higher fat than I personally would ordinarily eat as an ‘everyday food’ (because I follow the third type of low carb style of eating and am still in the weight loss phase), if I really wanted a pizza, I’d make it! I can plan for it ahead of time or adjust my eating for a little while afterwards to compensate, but eating this way does NOT involve food restriction.  It does require making some adaptation to prepare it differently, but there are plenty of websites geared to supporting those following a low carb lifestyle that have wonderful recipes.

I hope this post encouraged you that following a low carb or keto lifestyle is entirely doable, provides adequate essential nutrients from a wide variety of food categories. It is certainly not restrictive or nutritionally imbalanced and can be sustained for as long as someone desires to eat this way.

Want to get started, but need some help designing a Meal Plan just for you? I’d be glad to help.

Whether you live here in the Lower Mainland or live far away, the identical services and prices are available in-person or via Distance Consultation.

Have questions?

Please send me a note using the “Contact Me” form and I’ll reply as soon as possible.

To our good health!

Joy

If you would like to read well-researched, credible “Science Made Simple”  articles on the use of a low carb or ketogenic diet for weight loss, as well as to significantly improve and even reverse the symptoms of Type 2 Diabetes, high cholesterol and other metabolic-related symptoms, please  click here.

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