Thursday, August 31, 2017

Six Diet Tips Physicians Should Share with Their Patients

We are all exposed on a daily basis to a barrage of “healthy” diet and nutrition information - on television, over the internet, and in print. How do all of us sort out “fake” facts (unsubstantiated opinions) from advice based on solid science and medical studies? I recently ran across an article in an online medical journal that suggested six healthy eating diet tips (supported by multiple published studies in the medical literature) all physicians should shared with their patients as part of an annual wellness visit.

1. Avoid all processed foods.

Processed foods are all foods prepared outside the home. Examples include packaged snacks, smoked meats, white flour, sugar-sweetened foods, and of course sodas and colas. Why? Because of their high salt and sugar content. These foods are the source of more than 70% of the salt (a risk factor for high blood pressure in susceptible individuals) in the American diet and significant sugar in one form or another. As we face the twin epidemics of obesity and diabetes, sugar is now the “new tobacco”, to be avoided whenever possible. It is estimated that avoiding processed foods and drinking sugared sodas decreases one’s risk of dying rate by 10%.

2. Choose natural foods with a wide variety of colors and textures.

Replace those processed foods with natural foods - foods as close to their original, natural states as possible. Replacing processed foods with nuts, seeds, legumes, fruits, and vegetables will significantly improve your long-term health and longevity. As a rule of thumb, the American Heart Association recommends that at least one half of your plate be filled with fruits and vegetables.

3. Choose realistic, balanced diets for weight loss and weight maintenance.

A successful diet plan is the one that you can stick to. Many diets have proven effective for weight loss and weight maintenance, but  there is no single one that is easier or better.  When a diet fails, it is generally because it is too restrictive, unbalanced, or causes too rapid weight loss leading to a rebound weight gain and the vicious cycle of yo-yo dieting (lose - gain - lose).
The common factors in successful diets (which we should all make part of our daily eating) include:  
  • An increase in vegetables and fruits
  • An emphasis on foods high in fiber
  • More whole-grain foods;
  • Minimal sugar (especially sugar-sweetened beverages);
  • Adequate protein (especially non-meat protein)
  • Using healthy fats (oils).

4. Use healthy oils for heart health.

This includes a move to oily fish (such as salmon) which are rich in omega-3 fatty acids as our “meat” or protein for one or two meals a week, and cooking with one of the healthy oils - olive oil, avocado oil, canola oil, walnut oil, flaxseed oil, or chia seed oil.

5. Forego red meat and live longer.

Along with avoiding processed foods, this dietary change offers the most health benefit. Although red meat is the principal source of protein in our traditional American diet, research has repeatedly shown that consumption of red meat is linked to increased risks for cancer, diabetes, and cardiovascular disease.
Long term studies of over 100,000 health professionals followed for 28 years showed that cutting (not eliminating) red meat consumption - either by eating half servings of red meat or substituting fish, poultry, legumes, or nuts - almost 10% of the deaths could have been prevented.

6. Consume fermented foods/probiotics and fiber for gastrointestinal and overall health.

I’ve recently written several columns explaining the beneficial effect of certain colon bacteria (our microbiome) on our health. Adequate dietary fiber (from fruits and vegetables) keeps the microbiome healthy and in balance.  Probiotics (kefir; unpasteurized, fermented foods) contain microorganisms that may confer additional gastrointestinal benefits.

These six changes in your daily diet are based on multiple well supervised studies in the medical literature and will increase your overall health.  I think you are beginning to see a common dietary theme. More fruits and vegetables, less red meat (replaced with more soy, beans or fish to keep a healthy protein intake), and elimination of all sugars. Having tried to make these changes myself, I understand how hard it is to break personal food choice habits, and if you are the cook, your family’s eating habits as well. But keep at it. Even small changes will make a difference.

Monday, July 24, 2017

Anti-inflammatory Diets

When your body detects an invading germ, the immune system responds by sending white blood cells and antibodies to kill the bacteria or virus. When the battle is over, the attack is called off, the white cell count returns to normal, and the body returns to a surveillance mode. This process is called “the inflammatory response”.

A blood test for one of the many proteins involved in this battle, C-reactive protein, can be used to measure and track the inflammatory response.

When C-reactive protein is measured in large groups of people, we find that some study participants have persistently elevated levels suggesting a low level, chronic inflammation. As chronic inflammation can injure even normal tissues, many researchers have speculated that this inflammation is one of the factors involved in the development of some chronic diseases. And indeed, when monitored over time, groups with elevated C-reactive protein levels do have higher rates of diabetes, cardiovascular disease, and cancer.

If chronic inflammation can have that kind of effect on our health, is there anything you can do to minimize your risks? It turns out that what we eat will make a difference, and a diet low in animal products and high in fruits and vegetables will lower the blood markers of inflammation.

What is the reason a diet that is low in fruits and vegetables helps minimize this chronic inflammation? Unlike most of the cells in our body, which are nourished via the blood supply to various organs, the colon lining cells get most of their nourishment from small molecules (fatty acids specifically) produced by bacteria of the microbiome as they digest plant fiber. Healthy colon lining cells act like an internal “skin” to keep the waste products of the colon from leaking into our system, so if we starve the microbiome bacteria of adequate plant fiber, the colon lining suffers.

A high animal product (red meat) diet also increases the production of bacterial byproducts called endotoxins. These molecules are of no value to our body’s metabolism and in fact can be toxic. So if they “leak” into our body from the colon, our body tags them as “harmful invaders” and an inflammatory response is triggered as protection.

Eat too little plant fiber and the colon becomes leaky; add in red meat and the level of potential colon toxins increases. This combination results in repeated challenges to our immune system and thus chronic inflammation. Supporting this scenario, when patients with a chronically elevated C-reactive protein level are placed on a plant based diet (fruits and vegetables), levels will drop by 30 percent within two weeks.

Besides the positive impact of plant fiber on the colon lining cells (via the microbiome), many plants provide an additional anti-inflammatory benefit. Plants are high in antioxidants called polyphenols, and when the type of white blood cell that is involved in an inflammatory response is exposed to polyphenols in a test tube, the release of inflammatory molecules diminishes. Thus, these plant antioxidants provide additional protection as they work directly on the white blood cells to tamp down any tendency toward a chronic inflammatory response.

The benefits of a vegetarian diet are well known. Studies have repeatedly shown that the closer a diet is to a full vegetarian diet, the healthier and longer lived the individual. The benefits of an anti-inflammatory diet don’t require an “all or nothing” approach. Any additional fruits and vegetables will increase the fiber that keeps your colon healthy and any decrease in amount of animal products will decrease the endotoxin load.

If you are interested in moving towards an anti-inflammatory diet, the easiest first steps are to serve one meatless meal a week, cut down the portion sizes of meat on other days, and add the foods that have been demonstrated to lower C-reactive protein levels - fruits, vegetables, nuts, whole grains, beans, coffee and fish - as substitutes so you feel you have had a full meal. 

An even easier first step is to adopt my morning favorite, a tablespoon or two of flax meal with applesauce every morning to help nourish and rev up those good microbiome bacteria.

Tuesday, June 20, 2017

The Microbiome and Your Health - a few examples

Understanding how our microbiome impacts our health is one of the biggest advances in staying healthy in the last several decades. 

In a prior post, I promised examples to illustrate the significance of the connection between microbiome and overall health.  Those described below suggest that we can begin to use rational nutritional choices to modify the microbiome and provide new approaches to both avoid and treat chronic diseases. 

Weight Management - It looks as if our microbiome is involved in the current obesity epidemic by modifying how efficiently we use our daily calories, and may also help explain why some of us can eat anything we want and not gain weight. 

In one study bacteria from the large intestine (colon) of two twins, one lean and one overweight, were injected into the colon of genetically identical mice that had been raised in a germ free environment. They were then placed on an identical diet and after just two weeks the mouse that received bacteria from the heavier twin had 17% more body fat. It appears that the microbiome from an overweight person can signal the body to change how our cells use sugar for energy and store the rest as fat. 

 Have you changed to diet soda to lose a few pounds?  Studies in mice compared artificial sweeteners (aspartame, sucralose or saccharin ) and natural sugars ( glucose and sucrose). The mice given the artificial sweeteners experienced a documented change in the bacterial composition of their microbiome, and that change caused them to extract more energy from their food as well as storing more of that energy as fat. The result was the paradoxical effect of taking in fewer daily calories but not losing weight. 

Diabetes - Along with obesity, we are experiencing a diabetes epidemic in this country. The microbiome may be playing a role here as well. Mice given artificial sweeteners developed glucose intolerance (an abnormal glucose metabolism often referred to as pre-diabetes) compared to mice given the natural sugar glucose. When their feces were transplanted into germ free mice, these mice also developed glucose intolerance. Treating the newly prediabetic mice with antibiotics eliminated the glucose intolerance as the microbiome was altered. 

This experiment was duplicated in human subjects. Seven healthy volunteers were given artificial sweeteners for a week and four of them also developed glucose intolerance which, just as in the mouse model, could be transmitted to germ free mice with a fecal transplant. 

Not only is it possible that the microbiome is linked to the diabetes epidemic, it also offers us the possibility of a novel dietary treatment option. In a study of large populations, it was noticed that those that ate beans regularly had a lower incidence of diabetes. On further investigation it was found that the poorly absorbed carbohydrates in legumes are metabolized by colon bacteria into proprionate, a molecule which slowed stomach emptying and the rate at which dietary sugar is absorbed. Proprionate, given as a  rectal suppository, produced the same effect. 

But eating a half cup of beans a day and letting your colon bacteria do the work is more acceptable to most people. 

Heart Disease - Bacteria in the colon modify a protein in red meat (L-carnitine) into trimethylamine oxide (TMAO) which rapidly accelerates atherosclerosis in mice. TMAO can be measured in the blood, and the more red meat one eats per meal, the higher the TMAO blood levels. Thus it may be TMAO, not cholesterol or fat, that is the smoking gun that explains the association (in large groups) of a high red meat diet with a higher rate of heart disease. 

Interestingly TMAO is also formed from the metabolism of the amino acid choline. Choline is found in significant amounts in eggs and thus TMAO, not cholesterol, may also explain the link between egg consumption and heart disease. 

What can you do to maintain a healthy microbiome? 

  • Avoiding unnecessary antibiotics for “possible” infections is important. 
  • It is harder to avoid second hand exposure to the antibiotics in meat from animals raised on antibiotics as a growth strategy (yes, via their effect on the animals microbiome). 
  • Most experts agree that increasing fiber in our diet is the most important, and relatively easy, step we can take. 
  • Your regular diet has such a pronounced effect on your microbiome that there is little impact from adding daily probiotics. 

My suggestions: 

  • Eat an extra serving of vegetables with dinner. 
  • Decrease the amount of red meat in your diet (try to incorporate a meatless dinner once a week) 
  • Add beans to your diet as often as seems reasonable for your personal tastes Take your daily flax meal. 

Each of these will add their little bit to keeping your microbiome diverse and healthy.

Friday, June 2, 2017

The Microbome and Your Health

What we eat has a big impact on how healthy we will be.

It is generally assumed that it is the breakdown products of digestion (fats, sugars, and proteins) that are absorbed provide the energy for our cells and the raw materials for repair of injured tissues. But we are now finding that some of what we eat makes it to the colon where it is modified by bacteria before being absorbed. And those products of bacterial metabolism are also a key part of keeping us healthy.

Microbiome--a word most of us could not have defined 10 years ago--is now encountered daily on television, in newspaper articles and in advertisements for probiotic containing yogurts.

So, what is this mysterious microbiome? It is the collection of organisms (really an interactive community) that live on and in our bodies and includes all the bacteria, viruses and fungi that live on our skin, in our nose, our mouths and in our digestive tract. It is a diverse community calculated to consist of more than 10,000 unique microbial species.

Investigation of the microbiome has made huge strides using the same genetic techniques that have sequenced the human genome. PCR (polymerase chain reaction) is a tool that can rapidly identify and catalogue the entire collection of organisms that is unique to each of us.

How big is the microbiome? It has been estimated that 9 out of 10 of the cells in our body are microbiome organisms while just 1 of 10 are truly “us,” the cells whose DNA we inherited directly from our parents. But because bacteria are small compared to human cells, these organisms comprise only 3 percent of a body's total weight (2 to 6 pounds in a 200-pound adult).

The types and numbers means that microbiome organisms vary from person to person, and can change quite quickly depending on our diet and any medications we might be prescribed.

One study on the effect of diet on the microbiome compared the bacterial balance in the large intestine (colon) in three discrete groups - one on a full vegetarian diet, another on an unlimited animal product diet, and a third group that ate meat just once a week. The colon bacteria ratio in all three groups remained stable over time with the ratio of bacteria in the “meat once a week” group intermediate between the two extremes.

A recent study demonstrated how quickly a change can happen. Researchers looked at two groups: 1) Those on a plant-based diet rich in grains, beans, fruits and vegetables and 2) A second group on an animal-based diet of meats, eggs and cheeses.

Researchers again found a stable (and similar) bacterial population in each group, but in addition demonstrated that when a traditional vegetarian was changed to an animal-based diet, the ratio of bacteria could in just four days.

The bacteria, fungi and viruses that make up our microbiome can impact our health in two ways.

First, this stable community of thousands of organisms can help prevent infection with disease causing bacteria. It is thought that the microbiome controls the real estate, so to speak, and thus “crowds out” undesirable bacteria. When you take antibiotics, this balance can be upset, a niche for new bacteria opens up the chances of developing a colon infection with a new bacteria (C. Difficile Colitis is one example) increases.

The treatment? A targeted antibiotic specific for C Difficile which allows the normal microbiome to reestablish itself. With sensitive genetic testing, the C Difficile can still be detected in small numbers in some patients, but they are now held in check by the “good” bacteria.

The moral to this story is that you want to minimize antibiotic (and other unneeded medication) use as much as possible.

A second--and until recently less appreciated--health benefit results from our body absorbing and then utilizing the products of microbiome metabolism.

The food we eat is never completely absorbed in the upper digestive tract, and fiber (which is not easily digested) as well as a small amount of the proteins, fats and carbohydrates make their way to the colon where they are used as nutrition by the colon bacteria. It is these final products of their energy metabolism that are absorbed by the colon.

These “leftover” molecules that are absorbed through our skin or lining of the digestive tract provide their health benefits via their influence our daily metabolism or by modifying the effectiveness of medications we might be taking.

I suspect you have heard the phrase “we are what we eat.” That would assume that our health and our diet are interrelated. But now we have learned that it is more complex than just the direct effects of proteins, sugars and fats that are used by our bodies for energy and healing. Our health is also impacted by molecules produced by our microbiome.

We will review a few specific examples of how the microbiome can impact our health in my next column.

Sunday, April 30, 2017

Five “Must Haves” for the Pantry

There is solid evidence supporting the health benefits of a flexitarian diet. In short, lowering the amount of red meat in our weekly diet in exchange for more fruits and vegetables. Then in the last year we have seen the media focus on the potential benefits of decreasing our daily sugar calories, exchanging them for a few more fat calories.

If you’ve wondered if there are specific healthy foods you can ADD to your diet, here are five that should be in your pantry.

#1 - Vegetables (especially colored vegetables)

Your mom was right (again) when she told you to “eat your vegetables.” When diets have been analyzed for the ratio of meat vs. vegetables (adding points for plant based foods and subtracting points for animal products) the group with just a middle of the road score of 40 (60 equals a full vegetarian diet) experienced a 40 percent drop in mortality compared to the unlimited red meat group.  The study participants didn’t have to be full vegetarians to benefit from increasing their daily vegetable intake.

Colored vegetables provide an additional benefit. The colored pigment is incorporated into the retina itself where it helps to protect the retina from harmful uv rays. The result is a significant decrease in macular degeneration, the most common cause of blindness in the Western world.

#2 - Coffee

Although it was once speculated that coffee was a health risk, the facts are just the opposite. A 2014 analysis combined all the previously published studies assessing the health risk of coffee consumption.  It demonstrated that drinking coffee was actually associated with decreased mortality (the risk of dying for any reason). And the more cups of coffee a day, the lower the overall risk decreasing a maximum of 16 percent with four cups of coffee a day. 

There was no evidence for an increased cancer risk. In fact, a separate study actually demonstrated just the opposite, a cancer protective benefit with a 50 percent decrease in colon cancer recurrence in coffee drinkers compared with those who abstain from Seattle’s favorite brew.

#3 - Nuts

A study published in 2013 compared a group that rarely ate nuts to several others with varying nut intake. Those who ate nuts once per week had an 11 percent decrease in all-cause mortality which rose to 20 percent for those that reported eating nuts daily.  The protective benefits included reduced risks for cardiac disease, cancer, and a variety of inflammatory conditions.

Although nuts are traditionally considered highly caloric and fattening, another diet study demonstrated that a group that snacked on nuts actually lost more weight than the comparison group on a traditional low fat diet. The appetite suppressing effects of the nut oils appear to outweigh (sic) the few additional fat calories.

How many nuts? A handful, about an ounce (23 almonds, 14 walnut halves, or 21 hazelnuts) a day. And it needs to be whole nuts. Nut oils did not change the inflammatory markers in a study which compared nut oils to whole nuts.

#4 - Beans

A cross-cultural study attempting to identify specific foods associated with longer lifespans identified just one, legumes (Japanese - soy, Swedes - brown beans and peas, Mediterraneans’ - lentils, chickpeas, and white beans). There was an 8 percent reduction in overall mortality with just two tablespoons of beans a day.

The current recommendation is one-half cup a day. Canned beans are as good as dried beans. Canned beans contain significant salt so if you are on a low salt diet you should cook your own.

It is thought that the benefit of beans results from some of the poorly absorbed legume starches feeding our “good” gut bacteria in the colon. And it is the metabolic end products from the bacteria (microbiome) metabolism that are the beneficial agents.

# 5 - Flax meal

Fiber is a common component of all fruits and vegetables that helps to speed the progress of everything we eat through the digestive tract. The result is regular bowel movements which in turn decreases the time potentially cancer causing agents in our foods spend in the intestines. The result is both a notable decrease in colon cancer and as well as a blunting of the absorption of fats (which means a lower blood cholesterol) in those groups which eat high fiber diets.

In addition, phytates, the specific fiber in flax, appears to have a specific benefit in precancerous prostate changes as well as an independent benefit in the control of high blood pressure and osteoporosis.

Two tablespoons of flax meal in one-fourth cup of applesauce is an easy way to meet your daily fiber requirements without worrying about counting servings of fruits and vegetables.

So there you have it. Five foods that can easily be added to your daily diet. Start with a second cup of coffee in the morning, supplement your breakfast with a serving of a flax/applesauce mixture. Then, mid-morning, a snack of a handful of nuts to counteract the urge to snack on high sugar foods (and help keep the weight under control).  And finally, one-half cup of beans along with a colored vegetable as a side for lunch or dinner.

Wednesday, April 12, 2017

My Interests - Health, Nutrition, and Staying Fit

How did I get to be a columnist for the Beacon?  I’m told to avoid using “I” in my columns, but will ask for a pass on this column as I tell you a bit about myself and ask for your thoughts for future content.

I am a gastroenterologist (digestive, liver, and pancreas problems), now retired from The Everett Clinic in Everett. In my practice life, it was common to get patients’ observations on their diet and how it impacted their symptoms. I also fielded questions about personal nutrition changes patients could make to improve them. I was a digestive disease doctor so they naturally assumed I knew all there was to know about the food that digestive tract would need to process.

We didn’t focus much on nutrition in medical school, so I worked to expand my knowledgeable on nutrition in general. Staying on top of what was new in the field of foods and their impact on diseases and staying healthy became part of my regular reading and ongoing CME (continuing medical education).

When answering questions from my patients, I needed to provide the information in a way they could easily understand.  A brief explanation of the physiology helped them to understand the reasons a specific recommendation was being made, and understanding the connection would made it more likely that they would follow through. This reinforced my interest in effective patient education, and by extension a personal approach that crossed over into providing clear answers to other questions on medicine and physiology.
My interest in nutrition and education worked its way into my personal life as well. I was not an athlete in high school, in fact I hated PE. I ran my first mile when I was 30 and have stayed active running and bicycling. I started biking with a group of friends in the late 1980s and, being competitive, they would regularly turn to me with questions on nutrition and its impact on their performance.

Although there are now many books on nutrition and sports performance, there were none in the late 1980s. So I took my research of the literature, my advice to them, added in my interest in education and physiology, and wrote a short book on the subject of nutrition and bicycling performance - Bicycling Fuel.
In the 90s, I became interested in the Internet and decided to move my thoughts on nutrition and performance to a website.  As bikers’ (and other athletes’) interest in nutrition is really about their interest in improving their personal performance, I expanded the website content to include the physiology of exercise in general and training tips. That website Cycling Performance Tips ( continues to be my personal hobby.
Now that I am retired, a new set of questions have surfaced. Staying healthy. Staying active. Staying engaged in life. A friend is writing a book on the topic so we talk about it a lot. As I see it, it just an extension of the same questions I have been asked over the last 40 years.

When I was approached to in a column for The Beacon, it seemed a natural fit with my interest in education. My only question was “what topics”? So, this is where I make a public appeal. Please comment on past topics, on what areas you’d like me to explore in more detail and, of course, other ideas for the future. I’ve set up an email for you to contact me:

Send thoughts and questions my way. Nutrition, digestive problems, biking, and exercise physiology. I’ll do my best to avoid politics.

Monday, April 3, 2017

Where does exercise fit in a personal commitment to stay healthy?

Regular exercise can be so much more than just a way to control your weight. The truth is that everyone will benefit from regular exercise. Maybe you are fortunate enough to have an active day job and will get most of your weekly exercise there. But even if you are, it is likely that a little extra exercise time every week will yield big benefits as you age.
Here are four proven benefits of regular exercise:

Benefit #1 - Improved longevity
There is no question that those who exercise regularly live longer, more active lives than their sedentary peers. Numerous studies have proven the connection between an active lifestyle and living longer. This health benefit is independent of the weight loss effect experienced by those who exercise regularly. Best of all, the benefits are not age independent. That means a regular exercise routine can enhance life for people who do not start a routine until they are well into their 60’s and 70’s.
You not only will you live more years, but they will be healthier years. Regular exercisers miss fewer days of work, have a lower overall cancer rate, experience fewer heart attacks and suffer from fewer chronic diseases such as diabetes.

Benefit #2 - Improved strength and muscle health
Just living longer is not the only benefit of regular exercise.  You will also be able to continue those activities you enjoy for more of those days of your longer life.
As we get older, all of us gradually lose muscle cells. If the muscle is stressed (forced to lifting weight) the remaining muscle cells increase in size which then compensates for this inevitable loss of cells. Maintaining your strength means you can stay involved in your regular activities.
In addition, stronger muscles improve your balance which in turn decreases the risk of falling, and the flexibility that comes with regular exercise decreases the chances of a muscle pull or strain if a fall might occur.
Although it is impossible to stop the inevitable aging process, we can certainly slow it down with a regular exercise routine.
How much stress is needed to maintain strength? Three times a week of focused weight training will do the job, as will changing your daily routine to add activities which will make the muscles work a little harder - such as regularly taking the stairs (up as well as down) or adding hills to your daily walk.

Benefit #3 - Improved heart health
Those individuals who stay active have a lower chance of dying from a heart attack or from a blocked blood vessel (exercise stimulates the growth of  additional “collateral” arteries in the heart), regular exercise improves the fitness of the heart muscle cells which means you can exercise longer and harder before you tire out. And the fitness benefit requires as little as a dozen 20 second bouts of vigorous exercise three times a week. There have been many articles on High Intensity Training (HIT) lately if you want to find out more.

Benefit #4 - Brain health
Finally, we have the benefits of exercise on the brain. A recent study looked directly at brain cell development in exercised lab animals confirming an increase in the number of new brain cells with exercise. This supports the known fact that regular exercisers experience a slower rate of decrease in memory and mental function as they get older. And in the animal study, the longer the duration of the regular exercise routines, the more new cells were found.
How much exercise do you need to take advantage of the various health benefits of exercise? If you walk the equivalent of an hour a day, you decrease your chance of dying by almost 40 percent. And if you add 20 to 30 minutes per week of vigorous exercise (getting your heart rate up to 80 percent of your personal maximum heart rate or enough to break a sweat), you get an extra few percentage points benefit as a bonus.
Changing a long-standing routine is a challenge, whether it is moving to a healthier routine, a lower salt or lower sugar diet or regular exercise. Even though it is difficult, the benefits of adequate weekly exercise are clear. You will live longer while maintaining the ability to stay involved in life - both mentally and physically.
After all, isn’t that what life is all about??