I have been working on this for a while, and now can share that my first YouTube video has been posted!!!!
This first video is a shorter version of my free course on the different types of eating disorders.
Other videos are coming soon on debunking popular fad diets (starting with the "keto" diet) and medical complications of eating disorders.
Please go check out my channel, and subscribe to the channel to be notified when a new video comes out. Here is the link: www.youtube.com/channel/UCfmXodqj-5iWPqLYOVQI67Q
....and the video!
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As a RD, I have gotten so many questions about the fad diet du jour: the "Keto" or "Ketogenic" diet. I finally decided to just write down the research in a reader-friendly version. Additional video on the history and use of the ketogenic diet at the bottom of this post. Here you go-
The ketogenic (or “keto”) diet is just another fad diet.
The Keto diet is an amped-up Atkin’s diet (that we all know now was/is terrible for your cardiovascular system, and not a sustainable way to keep weight off) where the majority of what you eat comes from fat, and carbohydrates are extremely limited (In contrast, a healthy diet should be a much more balanced macronutrient distribution of 20-35% protein, 45-65% carbohydrate, and only 10-35% fat). This skewed macronutrient distribution is actually very dangerous for the human body for several reasons -
#1, We use carbohydrate as fuel for our brain. Glucose is needed for cognitive function, and many people on the Ketogenic diet experience brain fog and difficulty focusing. Ketone bodies (specifically: beta-hydroxybutyrate (built up in blood serum), acetoacetate (found in urine), and acetone (responsible for that bad breath)), which are created when carbohydrates are not present, are not as effective (or healthy) for our brain. This may also cause metabolic acidosis which is characterized by a reduced pCO2 and/or lower pH (we need to stay in balance!).
#2, On a ketogenic diet, your intake of fruits and vegetables is extremely limited (if eaten at all) and we all know how important the fiber, vitamins, minerals, and other compounds in fruits/veggies are. On that note…
#3, The keto diet is extremely low in fiber! Fiber is not only protective against many gastrointestinal cancers, it is also a big factor in fullness and weight loss. Furthermore, constipation is very common on low-fiber diets like the Keto diet.
#4, Ketosis/ketoacidosis is what is happening in the body/brain on a chemical level – this is the body making fat into something the brain can use when carbohydrates are not available. It's a lot of work for the the body to produce, not as efficient as carbohydrate, and can be incredibly dangerous for diabetics. Additionally, we have some cells with few-to-no mitochondria. These cells are carbohydrate-dependant and must be fueled by glucose. These cells include certain cells with no mitochondria in our blood (erythrocytes), eyes (cornea, lens, and retina); cells with few mitochondria include renal medulla, testis, and leukocytes. (https://link.springer.com/article/10.1007/s11883-003-0038-6)
#5, “Keto breath.” Halitosis (bad breath) from (acetone) ketone bodies makes for an acetone-like smell on your breath that no amount of brushing/mouthwash can fix. Medical professionals look for (smell for?) this in malnourished patients.
#6, High blood lipids/cholesterol/blood pressure. It’s a high fat diet- you didn’t see this coming? The body can only break nutrients down at a certain rate, and high levels of fat in the diet may lead to high levels of blood lipids are responsible for blockages (atherosclerosis), and other cardiovascular complications up to death. While you can reverse the numbers, the plaque buildup in arteries is almost impossible to reverse. Not worth it! (note: some people do see lowered blood lipid profiles on this diet).
#7, Following this diet is often a form of disordered eating or may lead to an eating disorder (just as with any restrictive diet). Cutting out whole food groups is not healthy. We need all 3 macronutrients in appropriate proportions (majority coming from carbohydrates) to have a healthy body. Our body needs a variety of foods for best health. The reason this diet “works” for weight loss is that it restricts the types of foods that people tend to over-do-it-on like chips, candy, pastries, etc. Any diet that cuts out your favorite foods will cause weight loss, but at what cost (physically and mentally?)
#8, Not all fats are created equal. Most people starting a Keto diet are not differentiating between saturated (solid at room temp, and not something we want in large quantities) and unsaturated fats (liquid at room temp, and “healthier”). Getting this wrong also increases complications from the diet. Additionally, many people who followed a diet high in medium-chain-triglycerides (MCT) experienced undesirable digestive issues.
#9, It may mess with your thyroid and other hormones – lowering your metabolism (isn’t the point of this diet weight loss? That’s counter-intuitive…), energy, and fertility. Every time we lower our metabolism through dieting it lowers the “set-point” of our metabolism, making it harder and harder to lose weight. This is an adaptive response for mammals in famine, but not what the average person wants nowadays.
Who it the Keto diet appropriate for?
The only population that the ketogenic diet is scientifically proven to be beneficial (and safe) for is a select group of people with epilepsy (seizure disorders). This is the position of the Academy of Nutrition and Dietetics.
The Keto diet especially sucks for athletes (and people working out to lose weight)
Since our preferred fuel source is glucose (carbohydrate) from either blood glucose or glycogen (fancy term for carbohydrate stores in the liver and muscle cells), running exclusively on fat slows athletic performance as the body works much harder to break down fat (dietary and adipose storage).
Additionally, the lower protein intake and change in hormones in the body with a keto diet lower the ability to build and maintain muscle mass. If “mirror muscles” like biceps are not motivating enough to keep you off it- remember that our organs like the heart are also muscle tissue that would be broken down by this diet, causing organ damage or failure.
It’ll get you, mentally and emotionally
Ketogenic diets cause headaches, brain fog, and often irritability and obsession with food. This type of diet will very likely make you think about food an unnecessarily large amount of time, and make it difficult to be social (not being able to eat at the same places as your friends; oh, and that bad breath!).
You may feel more depressed (especially if you are already prone to depression and/or taking antidepressants) as serotonin (the “happy” neurochemical) is produced from carbohydrates. If you take an SSRI know that this class of medications work directly on serotonin that is present, and the diet requires a minimum about of carbohydrate (as we learned from the works of Ancel Keys in his starvation study) to allow the SSRI medication to work.
So, what’s the verdict?
In case you didn’t get it from the above – the Keto diet sucks. Not only is it a fad-diet (aka – not suitable for long-term weight loss/lifestyle), it can be very dangerous.
If you need help figuring out what to eat, contact a Registered Dietitian. In the meantime, if you do need some structure, balanced eating like the Mediterranean diet or DASH diet is a better way to go.
For a YouTube video with more information on this diet: click the image below
Don’t give up the foods you love. There is room for all foods in a healthy diet. We just need to keep proportions and variety in mind to fuel our body optimally.
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Eating disorders affect approximately 10-13%
of college age females, and about 2-3% of college-age males.
Professionals have noted kids as young as 6 years old talking negatively about their bodies and trying to diet.
How can we help our kids navigate the world with
a healthy body image?
Over the next 3 weeks I am offering a free support group/class for parents in San Luis Obispo.
We will go over what eating disorders are, warning signs, how to talk to your kid/someone with an eating disorder, what you can do to model healthy behaviors, and whatever else you want to talk about.
This will be a safe space to talk about this stigmatized mental & physical illness.
Please invite your friends! This class is open to all.
While it is aimed at parents of middle/high schoolers, it is for anyone who wants to better understand what eating disorders are and how to help a loved-one.
I am not assuming that you or anyone in your family has an ED just because you showed up - this is good information for everyone, because we all know someone with an eating disorder.
Sundays at 6 pm, March 4, 11 & 18.
(Ideally come to all, but you can drop-in to any of them)
First Presbyterian Church (church library)
981 Marsh Street
San Luis Obispo, CA 93401
Hope to see you there!
Sign up for more free education whether or not you can make it to the classes:
I am thrilled to have this guest post about vegan nutrition!
Many of my eating disorder clients have adopted a vegan diet, for better or worse, and are not meeting their nutritional needs. Vegan and vegetarian diets are very healthy when done correctly, but if the whole purpose is to cut more things out in the name of restriction, then malnutrition is almost certain.
If you are vegan, or contemplating starting a vegan or vegetarian diet, read-on to learn about plant-based sources of certain nutrients that are often hard to get when animals are off the table.
The Vegan Diet - A Guide to Nutritional Needs
By: Emily Baird
Emily is a 1st year nutrition student at Cal Poly who plans to become a registered dietitian. She has been vegan for 2 years, and plans to incorporate that into her career.
Every year more and more people are making the transition to a vegan diet, and for good reason! The vegan diet can have so many health benefits for our bodies including disease prevention, weight management, and protection against cancers. But with being vegan, also comes the common questions about: “How do vegans get enough protein?” “How are they getting any B12 in their diet?” “How to vegans get calcium if they don’t drink cow’s milk?”. And although these are valid questions, a well-balanced diet full of fruits, vegetables, beans, legumes, and carbohydrates is all a vegan needs to fulfill their nutritional requirements.
Iron is an important component of the red blood cells that carry oxygen from the lungs to the rest of the body, as hemoglobin. Think of it like the engine to a car; the engine provides the car with the power it needs to make it move. Similarly iron allows hemoglobin to have the needed strength to get oxygen where it needs to go. Without it, the body cannot make hemoglobin, which means organs and tissues won’t get the oxygen they need.
There are two types of iron - heme and non-heme. “Non-heme” iron is found only in plants foods and is harder for the body to absorb than “heme” iron which is only found in meat products, so we need to eat more plant-based iron to truly get the same amount as if we were eating meat.
Many plant foods are naturally high in iron, but there are also many packaged foods that are now being fortified with iron. The recommended daily allowance (RDA) is between 8 - 18 mg (depending on age and gender, up to 27 mg during pregnancy). Be sure to include a source of vitamin C with your iron for better absorption.
VEGAN SOURCES OF IRON
1 cup soybeans: 8.8 mg
2 tbsp flax seeds: 4.1 mg
½ cup cooked lentils: 3.3 mg
½ cup fortified total whole grain cereals: 8 mg
(For a complete list click here)
Calcium is responsible for building and maintaining strong bones and teeth. When the body isn’t supplied with sufficient amounts, it increases the risk of developing disorders like - osteoporosis, hypercalcemia, kidney disease, and even alzheimer's. Calcium can be included either by nutrient dense foods or by incorporating calcium fortified foods. Most breakfast cereals, milks, breads, and juices contain added calcium, but be sure to read the nutrition label to be sure. The RDA is around 1000 - 1300 mg. Vitamin D intake is essential to adequate calcium absorption.
VEGAN SOURCES OF CALCIUM
100 g calcium set tofu: 350 mg
¾ cup calcium fortified plant milk: 240 mg
⅓ cup cooked kale: 110 mg
¼ cup dried figs: 95 mg
(For a complete list click here)
Zinc is essential for the body’s immune system to function properly. It also works in cell division, cell growth, the breakdown of carbohydrates, and wound healing. Although it is so important for our bodies, not much is actually needed; the RDA for zinc is 11 mg for men and 8 mg for women. Even though plant sources of zinc are not absorbed as easily as animal sources, vegans were shown to only have a slightly lower amount of zinc.
VEGAN SOURCES OF ZINC
Tofurky italian sausage: 9 mg
½ cup hummus: 2.3 mg
1 tbsp nutritional yeast: 2 mg
¼ cup roasted pumpkin seeds: 2.3 mg
(Click here for a complete list)
Your body must have vitamin D in order to properly absorb calcium in the body. Vitamin D is not typically a problem for vegans during the summer months, but those living in colder climate may be at risk of developing a vitamin D deficiency. The RDA is 600 - 800 IU. Just about 10 to 20 minutes (depending on skin tone) in the sun per day will provide the body with sufficient levels. But those living closer to the northern hemisphere, may need to include more vitamin D rich foods in their diet.
VEGAN SOURCES OF VITAMIN D
1 cup portabella mushrooms: 634 IU
1 serving instant oatmeal: 180 IU
1 cup fortified soymilk: 120 IU
1 cup fortified orange juice: 100 IU
(Click here for a complete list)
SHOULD I BE INCLUDING SUPPLEMENTS?
Eating a healthy variety of plants and grains will ensure that the body gets sufficient levels of nutrients. The exception to that is vitamin B12. Vitamin B12 is not as easily accessible through plant based foods, so it can be important to include a supplement in your diet. If you are overwhelmed by what kind of B12 supplement to choose, check out this article. Nutritional yeast is an example of a vegan food that does naturally contain B12. It is usually used as a cheese replacement or topping, and can supply 2.4 mcg per 3 tbsp (which is the RDA).
A well-balanced, plant based diet will supply the body with all the nutrients that it needs to thrive. There are many people who question the vegan diet and believe that vegans are lacking essential nutrients, but with the right knowledge of nutritional needs, a vegan diet can be very beneficial.
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I am so excited, because an idea I have had rolling around in my brain for months has finally come to fruition!
Yesterday, January 8th, I opened for enrollment my course for performers,
"Whole Health for Performers!" This course is "A scientifically-based mind-body approach to get the most out of yourself, so you can focus on creating the performance of a lifetime."
This class is aimed at non-pro level actors, dancers, singers, musicians, directors, drama teachers, and techies who get their heart rate up on (or back) stage.
We cover: Physical fitness, Eating healthy, even when you are busy, Avoiding digestive issues on stage, Hydration, Vocal health, Mental health in the theatre, Better coping skills, and more, with step-by-step "homework" with each module so you actually TAKE ACTION on your goals!
It is being offered at a low cost of $97 for beta testing. This means you get to be a voice in the creation of this course! I will be tweaking the course based on your suggestions, and will be offering free live Q & A sessions to overcome personal barriers in a private facebook group for those who sign up. I normally charge $125/hour for individual counseling, so this is a steal!
Keep your eyes peeled for more educational courses coming later this year! I have some free education available on the online education page under "services" - check them out too
(I admit they are my first online creation, and not the prettiest!).
If you are in the performing arts, and want to take better care of your body on and off stage, what are you waiting for? Go to the course now!
Don't just take my word for it, a wonderful article about this course was written by the creator of OnStage Blog. Here it is for more info:
Something I talk about frequently with my clients is the concept of "normal eating." We are all born with the innate ability to tell when we are hungry and when we are full. Our brain and gastrointestinal sensors help us to desire a variety of foods that will nourish our body... but somewhere along the way society can confuse our senses of what eating is supposed to be like. So....
In the dietetics and eating disorder industries, a quote about normal eating has become the gold-standard. Leading child eating-behavior-expert, Ellyn Satter's quote is as follows:
What is Normal Eating?
By: Ellyn Satter, MS, RDN, MSSW
Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it and truly get enough of it -not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good. Normal eating is mostly three meals a day, or four or five, or it can be choosing to munch along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.
In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.
This quote came directly from: http://www.ellynsatterinstitute.org/hte/whatisnormaleating.php
©2016 by Ellyn Satter published at www.EllynSatterInstitute.org
For more about eating competence (and for research backing up this advice), see Ellyn Satter's Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook, Kelcy Press, 2008. Also see www.EllynSatterInstitute.org/store to purchase books and to review other resources.
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How I experienced “To The Bone” as an eating disorder expert & Why you need to carefully consider if you should watch it
There was a lot of buzz leading up to the release of Netflix’s “To The Bone” on July 14, 2017. As a Registered Dietitian who specializes in eating disorders I was intrigued. In this film, actress Lily Collins played Ellen, a young woman with anorexia nervosa who goes into a couple of different treatment centers and bounces back out to home or hospitals. Collins has been very forthcoming that she previously struggled with anorexia nervosa, which made me more nervous about her losing weight for the role.
When I first heard that there was going to be a film made about eating disorders, I thought this would be a great opportunity to raise awareness of what eating disorders are like. And hopefully get people talking in a productive way about the different types of eating disorders and how it is not a good thing to get one...but as the trailer and initial interviews came out in the weeks leading up to the release, I instead became worried that it would not only depict the stereotypical white emaciated anorexic girl (which it did), and be triggering to those dealing with body image issues (it probably will), or teach new bad habits (for some it will - that scares me most of all!). Here is my take on the film as I watched it and took notes, the good, the bad, and the triggering (spoiler alert).
OPENING: I must commend Mockingbird Productions for starting the film with the statement, “The film was created by and with individuals who have struggles with eating disorders, and it includes realistic depictions that may be challenging for some viewers.” I hope they don’t consider that their liability statement, but they tried. In the opening scene we see “Ellen” at a residential treatment center in art therapy class. She looks visibly bony, and it only gets worse through the film (not sure if it changes due to eating less, make-up tricks, or what, they did claim the use of some prosthetic bones, though). In articles that came out prior to the film release, it was said that Collins lost weight under supervision of a “nutritionist.” I don’t know who this “nutritionist” was, but there is no way in a true health professional that knows a thing about eating disorders would allow someone to lose that much weight, ethically, especially since she has a history of anorexia and might suffer physical and mental complications of going through the trauma of extreme weight loss again. I also use “nutritionist” because that is the word I found for the unnamed person who guided her weight loss, and if it was actually a Registered Dietitian or other licensed health professional they would (or should) have their license revoked for unethical behavior.
Weight cycling (large fluctuations up or down) is very hard on the body, which likes to maintain homeostasis (or “same-ness”). Every time we lose weight our metabolism (calorie needs) goes down. When we gain weight back our metabolism does not go all the way back to “normal,” this is why it gets harder and harder to lose weight if you have been on many diets. In addition to lowered metabolism, as was briefly mentioned in the film, the body has to rely on energy (calories) from muscle and organ tissue to survive, which can cause irreversible damage. Having Collins go through extreme weight loss again could have done real damage to her body (organs, bone density, fertility, cardiovascular system) that she might not know about until years later.
CALORIE TALK: In the following scenes there are definite strengths and weaknesses apparent to anyone who is in the field of eating disorders. As seen in the trailer, there is a scene where Ellen is quickly counting calories on a dinner plate. This is a strength in that it is very realistic to how a person with anorexia’s mind typically works, but any time calories are brought up (in a few scenes) it is a potential trigger for some viewers. It also glamorizes the “ability” of knowing what is in your food. With so many people on diets that require calorie counting, I am sure many think it would be “easier” to have anorexia to be able to not only count fast, but to abstain from eating. If you are one of those people reading this - IT IS NOT WORTH IT! (Contact me personally, I will walk you through the why nots, I don’t have the space in this article). By the way, eating disorders (ED) are not a choice. They have genetic and environmental components and are a person’s way of coping with a perceived problem or trauma, similar to the way an alcoholic turns to alcohol to numbs themself from emotion.
BEHAVIORS: Continuing on, maybe it is because I live in a part of California where cigarettes are banned in public spaces, but smoking is not nearly as common among ED/weight loss as it was 10+ years ago. Ellen is seen smoking throughout most of the film, and I hope people don’t continue that stereotype along with most EDs being anorexia nervosa (they’re not - binge eating disorder and “other specified feeding and eating disorders” are much more prevalent).
Other behaviors throughout the film that the director/actors got right are body checking (Ellen keeps checking her arm circumference with her hand, and her roommate calls her out on it), flushing meds down the toilet due to fear of weight gain (don’t go off meds without Dr approval), the roommates “barf bag” and laxatives, cutting breading off of chicken, passing out when she stood up fast (this is caused by low blood pressure when not eating enough), stair running to “burn” calories, and the doctor noticing the bruises on the bones of the spine and calls her out on doing sit-ups.
WEIGHT: More triggering, but truthful scenes, include Collins taking off her shirt to get weighed, and at the end of the film you see her naked (artfully laid on the ground to cover private areas). She is truly emaciated. This took my breath away- as you can only do so much with makeup, she had to lose a lot of weight for this role. It makes me so sad. Near the end of the film (spoiler) she has a “dream” where she is healthy and happy, and she has some weight on (probably shot first before she lost the weight), and she is gorgeous. There are no bones protruding, she is on the slim side of normal weight.
The treatment facility where most of the film takes place did a good job of having a range of body types and disorders. Most people with ED are not underweight. There was a larger binge-eater, some average-size people with bulimia and anorexia, a male, a pregnant woman, and different races (though still overwhelmingly white). While the other behaviors of binge eating and bulimia were touched on, the film was primarily about anorexia. I wish they had shown more of the other disorders, to make a point that EDs are not just thin white girls.
PROFESSIONALS: I thought the doctor, therapist, and nurse were all very well written and played. Any of their interactions were probably my favorite part of the film. In group therapy, the therapist was great at getting the participants back on topic in a realistic way, and concluded a talk with “there is never thin enough.” The nurse and doctor being more upfront and brazen with their speech is likewise true to life. They all easily call out Ellen on her behaviors and things happening to her body (ex: lanugo hair, body burning muscle and organs when not eating) in very realistic ways.
TREATMENT: The treatment facility that most of the film takes place in is a good depiction (though a bit cleaner/newer than most) of a residential treatment center. They call it inpatient in the film, which is incorrect, it is residential. Something that seemed off to me, but maybe some places do this, is that the patients were allowed to eat what and how much they wanted for every meal with no real consequences, and most of the time no professionals ate with them. From my visits to and talks with treatment centers, there is always at least one staff member present, and if they do not finish their meal, typically a liquid supplement like Ensure or Boost would be required. I did like that the anorexic man said he gets a “crazy burst of energy” when he eats. I have heard that from a lot of my clients when they start eating again.
It was realistic for the nurse to go through Ellen’s bags when she arrived at the facility. They check for any diet or self-harm tools as depicted in the film. It might give viewers ideas about how to hide things when not in treatment, though, so that worries me. The bedrooms rooms not having doors is not necessarily typical, but there would not be locks on the rooms or bathroom.
When the families are talking about treatment modalities in the waiting room I did not like that they were putting down methods like “Maudsley” (family therapy for children with anorexia), and family therapy was depicted in a bad light. Both of these can be very helpful in real life.
RELATIONSHIPS: Ellens relationship with her family, though realistic, is not necessarily typical. Though many have tumultuous relationships with family members, they are not usually so blatant (but this is a movie - so it had to be interesting). Families are also typically not the “cause” of an ED, though relationships get harder as someone sinks deeper into their ED. ED is a relationship, and it makes it very hard to get close to, or let others into, your life. It was notable that Ellen was never hugged (except by sister) until the end of the film. Unfortunately, lack of touch (whether by choice, or because family is not affectionate) is a common thing I see in clients.
Something I think was unrealistic or glamorized was the relationship that developed between Ellen and the man in treatment. I have never heard of a relationship coming out of treatment, and if it did it would probably not be a healthy one. Also, can I just say that it was weird that right after she told him about her trauma of men and touch that he kisses her and climbs on top of her without permission? That seemed wrong and was uncomfortable to watch.
CONCLUSION: This film got a lot of things right about EDs and treatment, and the acting was very realistic. So realistic, that I had to process this for a day before I could write this article. Though I have had a healthy relationship with food and my body for years (after restricting in college), and treat people with all of these issues and symptoms every day, I had flash-backs to my personal struggles, and had to go look at myself in a mirror to remind myself I am not scary-skinny. The fact that that happened concerns me for how others who are not as strong in their recovery will handle seeing this. My recommendation is that if you struggle with body image or disordered behaviors (whether or not a diagnosable ED) you should not watch it, or be ready to process it with a therapist or trusted friend. This film has a great potential to trigger people who have these propensities, and to teach bad habits that help them “get away” with disordered behaviors. That being said, viewers could find those behaviors other places online, so it is not necessarily the fault of the filmmakers.
I do think this would be a good film to watch for those who have a loved-one dealing with an ED, especially anorexia. It is a realistic depiction of high-acuity anorexia nervosa, and discusses symptoms other consumer media leaves out.
*Article is re-printable with permission. Please contact Libby for permission to put it on your site.
Registered Dietitian, Libby Parker, is the owner of Not Your Average Nutritionist, LLC - a private practice on the central coast of California. Libby offers nutrition counseling for teen-young adult, specializing in people with eating disorders. Additionally, Libby teaches nutrition courses at a local college, and works to educate on topics of eating disorder recovery with her online training site. Find out more about Libby at: www.notyouraveragenutritionist.com (check out the "online courses").
You can also sign up for free educational emails here:
A common myth I hear from people is that we need to "cut out carbs."
No, we need the majority of our daily calories from carbohydrates.
Yes, different conditions require different amounts, but we still need quite a bit.
If we are eating the correct amount of calories for our needs our composition should be broken-down roughly into the percentages shown below.
I created a quick cheat-sheet for you about how much Carbohydrate/Fat/Protein we need.
(originally posted 7/21/2016. libbysfitnutrition.com)
People intrinsically want to believe and have hope in something. When “big-pharma” and doctors are not making patients feel significant and understood, people will go searching for healing elsewhere, this is where dietary supplements (DS) come in. Most DS work under the realm of “placebo effects,” unless they are being used to treat a nutritional deficiency.
The definition of “placebo effect” is, “improvement in the condition of a patient that occurs in response to treatment but cannot be considered due to the specific treatment used(1).” This phenomenon has been identified in several studies. One of which was a study of patients with irritable bowel syndrome (IBS) which “treated” patients with either “open-label placebo (non-deceptive and non-concealed administration)” or no treatment. Even knowing that the pill they were given was a placebo made of an inert substance, the sufferers found significant relief over those receiving no treatment. The conclusion was that “Placebos administered without deception may be an effective treatment for IBS (2).”
Doctors have long-known the benefits of placebo effects in patients and will utilize this in treatment. While the “placebo” thinking may help people heal, “no-cebo” thinking can render even an active drug useless. This phenomenon is summed up well in Henry Ford’s famous quote: “whether you think you can or cannot, you are correct.” It may be that doctors owe it to their patients to boost healing by any means possible, including treatment by placebos for more effectiveness (3). Nonetheless, the American Medical Association stated in 2006, that it is unethical for doctors to give patients undisclosed placebo treatment/medications (4). If doctors are ethically not allowed to give undisclosed placebos, then suggesting a DS labeled, “This product is not intended to diagnose, treat, cure, or prevent any disease” might be their way around this ethical dilemma.
Psychological effects of placebos
The placebo effect often is used, consciously or not, in the context of classical conditioning. Discovered by Ivan Pavlov, classical conditioning takes a neutral stimulus (which should cause no response - the “placebo”) and, through learned response, makes it a conditioned stimulus to elicit a conditioned response (5). An example of this in the medical setting would be giving a patient a pain medication that actually works to reduce pain every day for five days, then giving a sugar pill that looks the same on the sixth day and eliciting the same pain-reducing response.
The conscious expectations by a patient of a treatment to work may cause an inert substance to have a desired effect on the patient. These expectations can be elevated by how the health care professional (HCP) interacts with the patient. The study of medicine “generally does not pay adequate attention to psychological and social variables (6),” which are determined by the relationship of the HCP and patient. This may interfere with drug study controls. If the person in the placebo group of the study is getting attention and believes the treatment will work, then they may exhibit signs of the placebo working that may make the active treatment not have a significant desirable outcome over the placebo.
Yet, how can an inert substance elicit a similar response to an active treatment? A large part of this stems from the psychological variants at play. Much of the patient’s outcome may be determined by the HCP’s confidence in a treatment's ability to work, empathy, active listening, and care setting. “[it is] suggested that the success of the many forms of psychotherapy [are] due to a placebo effect rather than the distinctive features claimed by the different therapists (6).” Hope that it will work, and follow-through on actually seeking treatment, are other reasons that patients have better outcomes with either the active treatment or the placebo (7). DS are often prescribed either by licensed HCPs (like doctors) or “alternative healers” (like acupuncturists). The diplomas on the wall, or the attention given by the healer can contribute to the patient “feeling” the DS responding to treatment. Additionally, since chronic conditions often ebb and flow with severity, the patient is likely to look for treatment when symptoms are about to naturally decrease, leading to the belief that the DS “healed” them (8).
Physiological effects of placebos
Placebo effects are not “all in the head” as once thought. They can make actual physical changes in the body, under the right circumstances. A test group for an antidepressant medication versus a placebo showed interesting brain activity in the results. By viewing brain activity with fMRI studies, placebo responses increased activity in the prefrontal cortex of the brain, while the medication suppressed this activity. Both groups exhibited less perceived depression, though on different timelines (the drug working weeks faster than the placebo). To this finding, researchers said, “administration of an inert pill appears to be an active treatment rather than a no-treatment comparison as previously thought. [however, the] placebo response is not equivalent to an active drug response, since the two groups' brain physiology was altered differently (7).”
Even people with Parkinson’s disease can potentially have real physiological benefit from placebo “treatment.” The effect of the placebo increasing dopamine in the brain, modifying the neuron that is promoting the abnormal activity that causes the tremors (9). People in this study physically had reduced shaking while taking the placebo, showing that there is true physical effects in some placebo “treatments”.
Studies should have tighter placebo controls
The Food and Drug Administration requires new drugs to significantly outperform the placebo control before going to market (3). Placebo controlled, double blind trials have been the gold standard of research (8). However, most research studies for medical treatment (whether drug, DS, surgery, or other) could be better controlled for placebo response. This could be met with a few tweaks to methods of “treatment.”
Dr. John Farrar, a neurologist and epidemiologist, provides some insight into what can strengthen study design to control for placebo effects (3):
(originally posted 7/16/2016. libbysfitnutrition.com)
A paper I wrote for my Master's program class on dietary supplements. Bottom line- multi vitamin supplements may do more harm than good. If you cannot get all of your needed nutrients from food (which is totally do-able), then specific single nutrient supplements are a better choice than a multi. (HERE is a free handout on basic macronutrient composition we need to be eating.)
Here is the research:
Use of Multi Vitamin and Mineral Supplements for “Health Insurance” and Disease Prevention
Do “multi vitamin and mineral dietary supplements” have a place in health prevention and treatment? As will be discussed below, the answer appears to be a resounding no.
Background of Multi Vitamin and Mineral Supplements
Multi-Vitamin and Mineral Supplements (MVM) have been available to Americans since the 1940’s (1), and have only increased in use since that time. The general consensus is that a MVM contains three or more vitamins or minerals without other herbs or drugs (3); However, there is no one-definition for what a MVM is or contains (ingredient, number of ingredients, or level of potency). In fact, there are many dietary supplements (DS) on the market that are not labeled as MVMs that are essentially the same as other products labeled MVM (1). The 2011-12 NHANES data shows approximately 40% of Americans took at least one DS in the last 30 days (2). Many of the people surveyed listed to [maintain health, or prevent health problem(s)] as their reason for taking a DS (2). But what is the actual role of MVMs?
Usefulness, role, and dangers of MVMs
In the 1920s, the United States started fortifying major food sources starting with adding iodine to salt to counter widespread deficiency and prevent goiter. In the following years Vitamin D was added to commercially sold milk, and some B vitamins and iron were added to flour (3) minimizing deficiencies in the majority of Americans. Nowadays, many more foods for purchase are fortified with additional vitamins and minerals. With fortification meeting the needs of the general population, benefits of MVMs seem to be limited.
What is the reality of MVM use? MVMs may be beneficial if the blends of ingredients are tailored to the needs to the individual. According to the National Institute of Health (NIH), “several studies have found that MVM users tend to have higher micronutrient intakes from their diet than nonusers. Ironically, the populations at highest risk of nutritional inadequacy who might benefit the most from MVMs are the least likely to take them (1).”
Several large studies show this irony: In a large study of adult participants from Los Angeles and Hawaii, food frequency analysis showed that the majority of people (~75%) had adequate intakes from food alone (1). With MVM adequacy improved, especially for vitamins E, A, and zinc; but there was an increased risk of excessive intake, especially in vitamin A, iron, zinc, and niacin (1). A study of U.S. children under four, concluded that, “usual nutrient intakes were adequate for the majority of US infants, toddlers, and preschoolers, except for a small but important number of infants at risk for inadequate iron and zinc intakes (4).” They also noted that many children were at additional risk of excessive intake for folate, vitamin A, zinc, and sodium even without supplementation (4). Many children with autism are given MVMs, which are unnecessary, and contribute to excessive intake in many. Even with MVMs, there may be additional need for calcium and vitamin D in children, according to the Academy of Nutrition and dietetics (5).
There is an increased risk of nutrient toxicity when taking DS. The NIH states, “MVMs did not reduce the risk of any chronic disease (1).” and “There is potential for adverse effects in individuals consuming dietary supplements that are above the upper level. This can occur...in individuals who consume a healthy diet rich in fortified foods in combination with MVM supplements (3).” Typically MVMs have nutrient levels that are lower than the RDA for a particular nutrient, and without adequate food sources MVM users may need additional supplementation of nutrients (such as magnesium or calcium) not contained in high enough doses from the MVM; however, as discussed above, toxicity from supplementation is all too common (1), sometimes with irreversible health consequences.
Just a few examples of health issues caused by excess vitamin or mineral intake include: excess vitamin A or beta-carotene correlated to increased risk of lung cancer in smokers or former smokers (1); excess vitamin A (as preformed retinol) increasing risk of birth defects in fetuses of pregnant women taking supplements (1); and iron supplements have been noted as a “leading cause of poisoning in children until age 6 years (1),” due to children getting into supplement containers. Additionally, people taking blood thinning medications need to keep vitamin K levels steady, so any supplements should be checked and confirmed with their doctor before taking or changing doses (1).
Though many large-scale studies have been done separately with either male or female participants, there is not a significant difference in health risks between the genders. The Physician’s Health Study II was a large-scale, double-blind, placebo-controlled RCT of over 14,000 male doctors in the United States, the study showed that, “daily multivitamin supplementation modestly but significantly reduced the risk of total cancer (6).” In conflict, another study of the “295,344 men enrolled in the National Institutes of Health (NIH)-AARP Diet and Health Study (7) found that low-dose MVM use had no discernable increase in risk of prostate cancer, but those who took higher doses (more than 7 times/week) of MVMs had an “increased risk of advanced and fatal prostate cancers is of concern and merits further evaluation (7), than non MVM users (1). Another large study (n= 83,639) of male physicians found no association between cardiovascular disease and MVM use(1).
Women were no different in terms of conflicting research. A study of Swedish women (n= 35,329) found an increased risk of developing breast cancer with MVM use (1); while another study of U.S. women (n=37,920) “found no such association but did find indications that MVM use might reduce the risk of estrogen- and progesterone- receptor– negative breast cancer and breast cancer overall in women who consume alcohol (1).” Swedish women in a cohort study had a lower risk “of myocardial infarction when taking MVMs, especially when taken for at least 5 years (8).” A cohort study of Iowa women found a slight increased risk of mortality from long term MVM use compared with non-MVM-users (1). And finally, long-term MVM use appeared to have benefit for men but not women in total cancer and mortality risk in a NIH study, but no benefit to either group for CVD (3). Overall, the data is inconclusive of significant benefit to either gender taking MVMs long-term.
Is there still a use for MVM?
The NIH, Office of Dietary Supplements (ODS) states, “supplements cannot take the place of the variety of foods that are important to a healthy diet (1).” Eating a well-balanced nutritious diet is the goal for everyone, and can be done. That being said, there are populations that do benefit from taking specially-formulated MVMs or DS.
The American Academy of Pediatrics and the (formerly) American Dietetic Association, list potential populations that will benefit from use of MVMs: “[people with] nutritional risk....those who have anorexia or an inadequate appetite, follow fad diets, have chronic disease, come from deprived families or suffer parental neglect or abuse, participate in dietary programs for managing obesity, consume a vegetarian diet without adequate dairy products,..have failure to thrive...people with medical conditions and diseases that impair digestion, absorption, or use of nutrients [bariatric surgery]… some supplements might help people who do not eat a nutritious variety of foods to obtain adequate amounts of essential nutrients (1).”
However, not every MVM on the market is appropriate of any of these populations. In these scenarios, it would be far better to use specific formulations of needed vitamins and minerals to make up for lacking nutrients. The 2010 Dietary Guidelines for Americans, and the NIH–sponsored State-of-the-Science Conference, claims there is no supporting evidence for the general population to take a MVM to prevent chronic diseases (1, 7).
How should MVM be regulated?
Currently the Food and Drug Administration (FDA), or any government body, does not have the ability to test DS, legally (due to the Dietary Supplement Health Education Act, or “DSHEA”), or in resources (staff or funds) to do so. “Both the [FDA] and the Federal Trade Commission (“FTC”) regulate claims made by food and dietary supplement manufacturers (9).” The FDA regulates labeling, which prohibits false or misleading information on the supplement labels “under the Food, Drug and Cosmetic Act” (9). The FDA issues warning letters to manufacturers against law violations in labeling, but rarely uses other methods of enforcement (9) mainly due to inability to keep up with the booming DS industry. This means the regulating agencies are bound to fail when the staff is disproportionately small, and the enforcement of laws is poorly executed (9). If a DS was listed as a food additive, or drug, it would require pre-market approval (3), and there would not be the insurmountable task of keeping up with the production of DS.
While the FDA focuses on the direct product label, the FTC regulates the advertising of DS. This may include “evaluat[ing] dietary supplement labels if they are being used by an advertiser to promote the product...under the FTC Act, claims in advertising made about foods and dietary supplements may not be “unfair” or “deceptive” (9).” As presented in the American Journal of Law & Medicine, a “limited private right of action [private sector lawsuits] under the FTC act” would more easily bring “enforcement actions in federal court” to protect consumers regarding DS (9), and would greatly increase the amount of products being enforced.
The NIH has excellent recommendations regarding change in regulatory laws and action, for instance, “The FDA should have the authority to better inform consumers and health professionals regarding the existence of upper levels as well as the possible risks of exceeding those levels; [the FDA should] develop a formal, mandatory adverse event reporting system for dietary supplements; and mandate provision of a MedWatch toll-free telephone number or Web site on product labels to facilitate reporting of adverse events. Furthermore, we recommend that healthcare professionals, consumers, and manufacturers use the FDA MedWatch adverse event reporting system to report adverse events associated with the use of dietary supplements. Finally, we recommend that Congress revise and update the law to reflect current knowledge...design and conduct rigorous randomized control trials of the impact of individual supplements (or paired supplements, when biologically plausible) to test their efficacy and safety in prevention of chronic disease, using well-validated measures.(3).” Ultimately, DS should be regulated as drugs, due to the fact that they interact and “medicate” like drugs in the body.
Should this information change consumer behavior?
If approached properly, there may be a way to help consumers better understand the dangers and lack of regulation of DS. Two studies on consumer education about DS, showed that consumers taught about DSHEA and the regulation of DS “rated DS as less safe and less effective” than the control group (10). This gives us a starting place on what message needs to be making its way to consumers. “Consumers may be especially susceptible to health claims, because they usually lack the knowledge to assess claims referring to physiology or metabolic processes and may be especially impressed by purported scientific evidence bolstering the claims (9).”
MVMs, particularly due to the lack of content consistency, are not useful in human health and disease prevention or treatment. The Medical Letter, an unbiased publication for pharmacists, declares that long-term use of MVMs, or any substance, is not without risk; and taking vitamins A, C, E, or beta-carotene in high doses or long-term may be more harmful than helpful (12). They furthermore suggest the only beneficial supplements (in healthy people consuming a normal diet) are folic acid, vitamin D and B12, in specific populations (12). If supplemental nutrients are necessary for populations listed previously who cannot obtain enough from diet alone, they should be carefully chosen as individual (well-researched) DS, and not in MVMs which may (with or without accurate labeling) contain excessive levels of substances (vitamin/minerals, or drugs/herbs) that may be harmful. I strongly recommend against the use of MVMs given the research available to us today.
Libby is a Registered Dietitian focusing on eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community.
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