Weight | Bonnie Modugno, MS, RD

WHAT’S WITH WHEAT TODAY? Maybe it’s the gluten

May 21, 2013 by Bonnie

I notice when I eat bread I start to hiccup. So strange, but it’s been going on for years. I figured out the role of insulin resistance over twenty years ago and I eat mostly low glycemic starches. I grew up on pasta and bread, and learned in my 30′s that a high carbohydrate diet was packing on the pounds. I eat even less bread and fewer grains today, but I wonder if I can’t even handle that.

Monday I was feeling hungrier than usual, and knew I needed a bit more carbohydrate to be satisfied. I grabbed a few pretzels after a delicious Greek salad and headed out the door. I immediately started to hiccup. Ok, this is familiar. Then I started to burp and my belly felt tight and hard, like it was bloated. Yes, that happens sometimes, too. Minutes later my gut started churning. Soon I was hunched over in the car with a gripping kind of cramp. Nothing more, but I endured the distress for over an hour. What is happening?

There is evidence that since 1980 food sensitivities and food allergies are increasing. According to the Asthma and Allergy Foundation of America (AAFA) website 20% of all Americans today suffer from allergies and asthma:

Approximately 6% of allergy sufferers have food/drug allergies as their primary allergy.
Food allergy is more common among children than adults.
90% of all food allergy reactions are cause by 8 foods: milk, soy, eggs, wheat, peanuts, tree nuts, fish and shellfish.

WHAT IS CAUSING MORE FOOD ALLERGIES?

The AAFA website doesn’t address what may be causing the increasing incidence of food allergies. The Allergy Kids Foundation suggest environmental chemical contaminants could be to blame. This hypothesis is increasingly provocative when you realize that industry spews tens of thousands of chemicals into our environment. The compounds infiltrate the air, soil and water and eventually end up in the food supply. These compounds also bio-accumulate throughout the food chain. Those of us at the top bio-accumulate the most. We track only about 200 of these agents, and study even fewer. Who knows the role they play?

There is also much speculation regarding the role of genetically modified and engineered foods. There is no genetically modified wheat used commercially in the US, so I can rule that out in my case. Still, the jury is out on the role of genetically modified foods in the role of food allergies. In a 2007 review, the author concludes the paper by asking, “Where is the scientific evidence showing that GM plants/food are toxicologically safe, as assumed by the biotechnology companies involved in commercial GM foods?”

WHAT HAS HAPPENED TO WHEAT

Most of my symptoms surface when I eat wheat. The wheat we eat today is very different than the wheat families consumed decades ago. Today wheat doesn’t grow as tall and can easily be harvested with mechanical equipment. A recent USDA publication asserts that changes in wheat protein concentration are not significant, not likely the cause of increasing incidence of celiac disease, and suggests maybe it’s the imported wheat gluten. I’m not convinced.

In the NY Times best seller, Wheat Belly, Dr William Davis states two different protein fractions are probably causing harm, both gluten and gliadin. Both quantity of wheat and wheat protein content increased during the 21st century. The protein content of wheat allows bread to rise–a desirable quality. It is not much of a stretch to think farmers figured this out. In addition, the use of artificial fertilizers (which has been the norm especially since the 1950′s) is known to increase the protein content of wheat. What is behind the drive for greater protein content in wheat? In a word, profits.

A 2012 study of active duty US military showed a 400% increase in celiac disease ( a severe form of gluten intolerance) between 1999 and 2008. No one really knows what causes celiac disease, but it indicates that your gut experiences a dramatic inflammatory response to gluten that results in a damaged GI tract. The solution is to eliminate food sources of gluten. Of note, the greatest increases were seen in people in their 40′s and 50′s. Could this be happening to me?

Yesterday I purchased a bag of gluten free pretzels and a few other items. After a few handfuls, no hiccups, no burping, and no bloating or cramps. This should be interesting.

Filed Under: Blog Tagged With: carbohydrate, celiac disease, farming, GF, gliaden, gluten, gluten free, gmo, health, insulin resistance, profits, protein, USDA, weight, wheat, wheat belly, whole grains, William Davis

Are You Treated Differently Because of Your Weight?

May 4, 2013 by Bonnie

What rational basis is there for people — any people — to be biased against other people because of adipose tissue?

Eating contests push all my buttons. In this picture there is one large contestant and one small. Which image challenges you the most?

Dr. David Katz asks this provocative question in his recent Huff Post Blog, Obesity, Bias and Bedrock. While the question is meant for everyone, doctors and other health professionals are the primary target. Dr. Katz takes his cue from Tara Parker-Pope’s piece in the New York Times, Are Doctors Nicer to Thinner Patients? The dark truth is that patients of size have faced medical bias and worse for decades, certainly longer than the 26 years I have been in private practice.

Dr Katz mentions biology, suggests a role for anthropology, but fails to ask his colleagues to look in the mirror. From my perspective one of the biggest reasons patients experience weight bias is because medicine pretends weight has much more to do with health and disease than it actually does.

WEIGHT IS A POOR SURROGATE MEASURE FOR HEALTH

Measuring weight and calculating BMI scores is fast, easy, and inaccurate. Metabolic health is the critical indicator, but more time consuming and expensive to assess. So, doctors continue to measure weight, remark about weight and lament when patients don’t lose weight despite evidence that says weight doesn’t accurately assess health status. In addition, preoccupation with a number on the scale completely ignores the fact that how you lose weight matters.

Patients lose weight but cholesterol doesn’t drop, blood sugars don’t get better, blood pressure doesn’t decrease. It is a myth that a 10 pound weight loss improves health. The truth is that lifestyle changes help the body to use fat more effectively for fuel. A healthier metabolism improves health status and weight loss is the result of better metabolic health, not the cause.

FOCUS ON WHAT REALLY MATTERS

Maybe medicine needs to stop pretending that weight is an indicator of health. It isn’t. If health care professionals are serious about decreasing weight bias, they can focus on what really matters:

Ask your patient if anything about their metabolism is of concern or keeping them from living the life they would like to enjoy. Keep the focus on metabolic health and resist using weight as short hand.
Discuss what kind of activity patients enjoy, or if they have time to be active. What holds them back? Give them an opportunity to consider what they could do. The more patients own the plan, the more likely they will make an earnest effort to follow through. If they can’t, there is more to be discussed.
Ask patients about their diet. Resist leaning on one or two soundbites of advice. Be ready to listen without judgment. Give your patients a safe place to discuss what is not working. Ask them if they are interested in getting some help with that. Then if you don’t have the time or expertise to take it further, refer them to a registered dietitian or qualified nutritionist.
Consider what else could be getting in the way of effective energy metabolism. Stress plays a powerful role, so does lack of sleep. Medications often interfere with energy metabolism; some cause dramatic weight gain and even diabetes.
Stay open to the concept of healthy at every size. (HAES) There are many people who are living large– and are metabolically healthy.
Scrutinize your own beliefs and values. We are fast evolving from the simplistic notion that a larger body just eats too much. A sympathetic and non-judgmental ear is far more encouraging than even the slightest hint of shame or blame.

It is clear to me that weight bias exists because too much value is given to the number on the scale. If doctors are serious about eradicating weight bias, they need to figure out a more accurate and honest way to assess health. Have you been treated differently because of your weight?

Filed Under: Blog Tagged With: activity, David Katz, Dr. Katz, eating, eating contest, fat, fat bias, HAES, health at every size, health care, judgment, metabolic health, NY Times, obesity, scale, shame, Tara Parker-Pope, weight, weight bias, weight discrimination

Attitude Counts: What Does Exercise Mean To You?

February 24, 2013 by Bonnie

Some people live to exercise, others embrace their couch. Many know they should exercise, but they struggle with ambivalence. I remember bribing myself to run in college. I really didn’t like it, but I thought it was the best exercise to manage my weight. Today I wake up wondering what I will do to be active almost every day. Recent research reported in the Wall Street Journal begins to explain why people have such different experiences moving their bodies.

BEYOND MOTIVATION AND DISCIPLINE: WHY ISN’T EVERYONE ACTIVE?

Too many people looking to improve their fitness get hurt or demoralized when they push themselves (or someone else pushes them) too hard. What you can do may not meet expectations of what you think you should be doing. In the Wall Street Journal article I was especially taken by the examples mentioned by Iowa State University researchers. There isn’t one right way to exercise, just as there is no single right way to eat. Interestingly I have personal experience with each of the scientist’s observations:

WORK WITH YOUR BODY: Stories in the popular press seduce readers. People don’t realize how often the stories aren’t true, and the pictures are photo shopped. Years ago I remember our local paper featuring one young actress with her secret diet plan detailed in a sidebar. My jaw dropped. I had been seeing that same actress for months as she struggled with a raging eating disorder. Her food intake didn’t look anything like what she (or the journalist) claimed she was eating. When I asked her about the piece she started crying, knowing that she had lied to protect her privacy. What works for someone else may grab your attention, but what really counts is what works for you.
CONSIDER WILLINGNESS, READINESS AND ABILITY: Changing any behavior requires all three factors working in concert– and sometimes it is complex. I once worked with a client who wanted to lose weight and take care of his health, but he said exercise gave him the same feeling as a panic attack. He worked with a therapist to tease apart the physical experience of panic and the physical sensation of exertion, hoping to gain some insight–and cultivate a skill set to manage his experience. He stopped working with the trainer because he felt he could never meet her expectations.
EXERCISE WITH MUSIC TO INCREASE EFFORT: My son is a strong and able cyclist, but that wasn’t always the case. Those early years he struggled to ride with any measure of intensity, as if he was stuck in slow motion. My husband and I are avid cyclists, and we often worried that Noah would never get up to speed. Then he started to listen to music. He’s a drummer and responded readily to the rhythms. We gave him access to i tunes and the rest is history. Today he leaves me in the dust.
MOVE WITH JOY: I bribed myself to exercise right through my 20′s. I was 31 and teaching four classes, seeing private clients and planning a wedding in six weeks. And I was running–until one day I just stopped. I was exhausted and tired of pushing myself every minute of the day. I remember stopping on the boardwalk in Venice Beach and walking the rest of the way home. Instead of glancing at my watch every few seconds wondering when it would be over, I noticed how invigorated I felt as I gazed at the ocean and the blue sky. I haven’t run for exercise since. But I bike everywhere, enjoy yoga twice a week with friends, swim when I can, hike the local mountains and walk the beach, along with other more recreational “play”.

NO PAIN, NO GAIN IS NOT TRUE

Too many experts identify the best exercise as one that gets heart rate up or burns the most calories or creates great definition. Many trainers still drive clients to “go as long as you can, as hard as you can.” I believe this thinking is exactly why so many people don’t enjoy physical activity. I remind my clients that ever increasing goals work for some, but not for others. You don’t have to keep getting more and more fit to be fit. At some point all that intensity can blur the line between fitness and compulsion.

Too often we celebrate the biggest, the strongest, the fastest and the leanest. We also assume that the most accomplished athlete or the person with the “best body” is ideally suited to helping others get with the program. Maybe we need to stop making such superficial assumptions in fitness, diet, and weight loss arenas. It is easy to tell someone to do what works for yourself. It takes real skill and education to help someone figure out an approach to diet or physical activity that works for them and can be incorporated into their life.

Physical activity allows the body to use both glucose and fat better for fuel. With better metabolic health comes less risk of disease no matter your body size. Exercise allows us to release tension in our muscles and truly restore ourselves. People often sleep better and enjoy better digestive health when they integrate physical activity into their day. It is critical that everyone figures out how to integrate physical activity in their life, not just people who can’t live without it.

Filed Under: Blog Tagged With: coach potato, competition, discipline, exercise, expectations, fitness, metabolism, motivation, music, pain, slow metabolism, weight

Dietitians Not Eligible to Independently Treat Obesity

November 26, 2012 by Bonnie

The Centers for Medicare and Medicaid Services (CMS) has decided that there is enough evidence to conclude that intensive behavioral therapy (IBT) for obesity is important to help prevent illness in the future. In the world of “be careful of what you wish for”, there are unfortunate consequences to the decision. Two parameters–who is eligible for services and which practitioners are eligible for reimbursement–give me pause, and I am looking to join other dietitians in convincing CMS to reconsider their decision.

WHO IS ELIGIBLE FOR REIMBURSED TREATMENT?

The criteria for who is eligible for services is clear: People who are already considered “obese” with a BMI of 30 or greater. Yet a BMI score of 30 is not all that reliable to determine obesity. Many athletes or people with significant lean body mass can reach a BMI of 30 without being “obese”–or even overweight.

The first tragedy in treating “obesity” is that inevitably weight is the measured parameter. This sets up the unfortunate precedent of waiting until someone is already at a BMI of 30 to pay for any treatment. Talk about chasing the horse literally years after it left the barn! One dietitian I know describes our current health care system as basically a disease treatment system. I mostly agree.

Why aren’t practitioners able to address the problem as soon as they see it? Infants who are fast growers are already at risk. It is obvious when a child is gaining too quickly. Teens often experience unwieldy weight gain during puberty. And too many adults who got away with a poor diet during their early years don’t get away with eating whatever they want forever. Why do we wait for them to be obese before we step in with appropriate support and counseling? I know people seeking bariatric surgery for obesity that gain 25 additional pounds on purpose in order for the procedure to be covered by insurance.

CMS relied on three physicians, a lawyer and a health analyst to prepare the memo. I wonder if anyone considered the possibility of promoting health at every size? (HAES)

WHO WILL BE REIMBURSED TO TREAT OBESITY?

CMS also decided that the only professionals eligible to bill for these services are physicians and primary care practitioners, such as a nurse practitioners or physician assistants. Registered Dietitians (RDs) are not included. RD’s will continue to be allowed to treat obesity, but the language of the decision makes clear that dietitians and the following practitioners will also not be allowed to directly bill Medicare or Medicaid for treating obesity:

psychologists (who ironically have provided the bulk of the research regarding the benefits of intensive behavioral therapy for obesity)
mental/behavioral health providers, social workers, counselors and specialists
pharmacists
exercise specialists, exercise physiologists, exercise therapists and exercise scientists
diabetes nurse educators and other nurses
board certified behavioral analysts
preventive medicine specialists
athletic trainers, appropriately certified personal trainers, kinesiologists, sports medicine physicians
academically prepared professionals with specialized experience in obesity
occupational therapists
bariatric surgeons, bariatricians, obesity medicine specialists, bariatric medicine specialists
trained non-clinical providers, lay providers, peer health educators
PhDs, surgeons, physicians, cardiologists
commercial weight loss programs

That’s a formidable list, some with dubious credentials to “treat obesity.” No wonder CMS puts the brakes on. The irony in all of this is that studies show medical students are poorly prepared to treat obesity. Efforts are already attempting to help physicians in practice to become effective. But with 7-8 minutes per patient visit, how effective can these primary care doctors become? As for the nurses and physician assistants, I’m not sure that they have the skill set either.

How many allied health care professionals take more than a single class in nutrition? How many of them understand the role of exercise and metabolism? How many of them have the time and know how to work with the complex behavioral changes involved with purchasing and preparing food as well as navigating an increasingly abundant and adulterated food supply. Too many clinicians tell patients that they need to lose weight. Six months later and a few may be surprised, others may be disappointed, and too many basically give up when little has changed.

Counseling to improve metabolic health is not as simple as prescribing medication. Current paradigms put too much focus on the outcome of weight loss. The process often gets inadequate attention. Throughout the process a patient benefits from an opportunity to assess their personal readiness, willingness and ability to achieve stated goals. They have an opportunity to figure out what approach to food works for them. The resistant patient often needs a lot more support to navigate any one of these arenas.

In the end, my guess is there will be few individuals who will be able or willing to pay out of pocket to see a dietitian or other practitioner in private practice if the services are readily covered if they are performed in a physician’s office. Will primary care providers make adequate professional resources available “in house”?

CMS MISSES THE MARK

The CMS team missed a critical opportunity to redirect everyone’s attention to the real issue, metabolic health. Instead, CMS continues to pretend measuring weight is a good surrogate for measuring health. How utterly misguided.

In the future how dietitians and other practitioners work with eligible patients may be largely determined by someone other than the person who has more expertise and is doing the work. I am concerned that treating obesity will become a profit center for primary care practitioners rather than a place where appropriate resources are effectively directed to the patient.

I don’t know if there any chance to challenge this position. But I need to do something. I want to start by collecting the stories and experiences of my clients in their own words. If you would like to share your story you may attach a document or write it directly via email at contact me. I look forward to hearing from you.

Filed Under: Blog Tagged With: BMI, body composition, CMS, dietitian, HAES, intensive behavioral therapy, medicare, nurse practitioner, obesity, physician, physician assistant, reimbursement, weight, weight loss

Plus Size Argument–What happens when a larger body size is confused with poor health

August 29, 2012 by Bonnie

On August 26, 2012, The Los Angeles Times business section celebrated the growth and profit potential of plus sized clothing. With most trendy clothing designed for skinny model types, I join the chorus of cheers.

Today, letters to the editor weigh in on the opportunity for “plus-sized” women to buy fashionable clothing as more designers and manufacturers realize the business opportunity that has been in front of them for decades.

Two of the letters to the editor perfectly capsulized the polarized thinking on this issue. I found myself nodding my head as the first writer recalled a day when normal clothing ranged to size 18. There was no such thing as size “0″. I have often wondered how size 14 became a plus size. It is even more bizarre that a size fourteen is plus sized whether the women is 5’4″ or 5’10″.

CONFUSING BODY SIZE AND HEALTH

As I read the second letter, I found myself shaking my head. The second writer attempts to shame designers. He seems confused on a couple of fronts. He laments the efforts to design fashionable clothing for larger women because it ” only encourages the customers to ignore the fact that obesity is a national problem”.

The “gentleman” seems appalled that a larger woman could feel beautiful or proud of herself, unfortunately confusing body size and health status. Too bad he has plenty of company. Both conventional medical thinking and the media encourages him to do just that. In our society and in the medical world fat bias is real and very ugly–as if shame and ridicule could encourage effective change.

HEALTH AT EVERY SIZE

Body size is not a litmus test for health. Either is one’s BMI or clothing size.

Everyone deserves to feel comfortable in their body and in their clothes. Clothing that is well made and fits well is a pleasure. In my years of practice I have observed women stand taller, move better, and eat more healthfully when they feel their best. For that reason alone, I often encourage my clients to make sure they have clothing that fits–even as they endeavor to eat better and work with their body to use fat for fuel.

There is something absolutely luscious and joyful in the photo of real women. As for the skinny model types, I am not sure why we continue to celebrate the problem. I vote for healthy at every size! How you do weigh in?

Filed Under: Blog Tagged With: beauty, BMI, clothing, fashion, fat bias, HAES, health, health at every size, HealthMedia, media, plus sized, skinny, weight

Rx: Fasting to treat metabolic diseases

August 19, 2012 by Bonnie

Who says history doesn’t repeat itself? This week news agencies are reporting research by the Intermountain Medical Center Heart Institute heralds fasting as a potential treatment for cardiovascular disease and diabetes. The findings were presented on April 3, at the annual scientific sessions of the American College of Cardiology in New Orleans. That was awhile ago, so my first thought is that August must be a very quiet time for news.

My second thought is that the researchers must be pretty young or didn’t do a thorough literature review. Fasting was a common treatment for elevated triglycerides and other metabolic conditions when I first starting training in hospitals in the late 1970′s. Doctors ordered “NPO” (nothing by mouth) for a week. Most metabolic parameters improved.

I am not sure why these researchers are so surprised by these findings today.

FASTING IS ONLY THE FIRST PHASE

No question, the immediate impact of fasting quiets down a great deal of the metabolic noise. So researchers are always going to like what they see in short term studies.

The complications are only apparent after a significant enough time or repeated bouts of fasting. Periodic fasting can lead to lower overall metabolic rates. Anorexics are shown to lose up to 40% of their usual metabolic rate. Chronic dieters are also at risk for a lower metabolic rate that makes it more and more difficult to manage their weight.

Too often people break a fast with rebound eating. If there is excessive carbohydrate, especially refined carbohydrates, re-feeding edema is likely. People can gain 3-5 pounds over night. If that triggers compulsive eating or “what the hell” effect, the outcome can be more problematic that the original concern.

QUESTIONS STILL REMAIN

The intriguing part of this work is the intermittent part. The metabolic consequences haven’t been studied as well in controlled circumstances. This is where the length of the study will come into play and who they study. If they study people with relatively healthy metabolisms (ie: young active lean males) I can predict there will be little negative side effect. Other populations will probably not fare so well.

Before you decide to try intermittent fasting on your own, I encourage to remember these words of caution,

While the results were surprising to researchers, it’s not time to start a fasting diet just yet. It will take more studies like these to fully determine the body’s reaction to fasting and its effect on human health. Dr. Horne believes that fasting could one day be prescribed as a treatment for preventing diabetes and coronary heart disease.

This last statement gives me pause. Red flags wave when a researcher seems invested in a particular outcome.

Filed Under: Blog Tagged With: cardiovascular disease, diabetes, fasting, health, heart, metabolic rate, metabolism, obesity, starvation, weight

Welcome to the “Post Pasteurian” Era

June 16, 2012 by Bonnie

It is all becoming clear: Eating less carbohydrate, more whole foods, a stronger intake of protein and fat, less carbohydrate, the magic of raw milk, the benefits of eating close to the earth.

Mark McAfee, owner of Organic Pastures, Fresno, CA

What we eat feeds the bacteria in out gut. They have a profound influence on our immune system, inflammation, how our body perceives hunger and satiety–and we can only guess how much more.

Research regarding the human microbiome hit scientific journals this week in what could be described as swarm tactics. This insight will trigger an explosion of new theories. It is a game changer.

THE MORE WE LEARN, THE LESS WE KNOW

Dr. David Relman, a microbiologist from Stanford says, “The whole business is humbling. It seems like the more we learn, the less we know.”

Ironically, I have been searching for this piece of the puzzle for years. The clues have been accumulating, first from observing myself, and then my clients.

Back in the early 90′s I started counseling clients to eat less carbohydrate (especially less refined sugar and starch), more protein, and more healthy fats. I thought I was helping them manage their insulin response to food. I still do. But now I realize we were also feeding the bacteria flora in their gut.

EXPLORING INSULIN RESISTANCE

It seems I have always struggled with food. I remember blowing up like a balloon when I overate. I could lose weight readily when I stopped eating, leading to a nasty eating disorder in my teens. Much later on I realized a higher protein diet with far less carbohydrate was better for me. In the late ’80s this behavior was blasphemy. High carbohydrate, low fat eating was the diet of the day, but it didn’t work for me.

After regaining my health and my sanity, I started digging into the research and published my first paper regarding insulin resistance. (SCAN PULSE, Fall/1995) For over 20 years it has given me great satisfaction to share my insight.

Most of the time people benefit when they shifted to more whole foods, less refined sugars and starches, more protein and healthy fats. Good enough. But there were always curiosities that I couldn’t explain.

CONNECTING THE GI DOTS

After shifting his diet, one client came in complaining that he had just bought a case of Prilosec to treat his GERD (What used to be called heartburn), and he didn’t need it anymore.

Other clients would surrepticiously tell me about their bowel function improving. They enjoyed more regularity and no longer complained about constipation or diarrhea.

I remember one client with severe colitis. He was horribly depressed as he couldn’t leave his home and was in danger of losing his business. He slowly regained his health. We knew we had identified the culprit when he went to the movies one night and ate a bag of candy. The next 48 hours were miserable.

I had one young client see me for weight loss. She also had Crohn’s disease. She lost weight and her symptoms improved. Little did we know that an approach to food to improve her metabolism was also influencing the microbiota in her gut.

A 17 y/o male came in complaining about severe vomiting, especially in the morning. Doctors had no clue. We cleaned up his diet, added enough protein and the vomiting stopped.

LESS INFECTION, LESS INFLAMMATION

Other clues started to stack up. One client with interstitial cystitis struggled with repeated bouts of antibiotics, but no sustained benefit. She got better eating close to the earth. Another client reported incessant urinary tract infections, but they subsided eating more protein and fat, less carbohydrate.

I watch my own son. His body reacts intensely to what he eats. I know when he is eating more carbohydrate than he can handle. His body swells. His demeanor changes. He is ravenous and can’t get satisfied. Eating fewer grains and less refined sugar is critical for his well-being–despite the addiction-like attraction to just these foods.

EATING FOR THE MASSES (of bacteria in our gut)

What we eat influences how our body uses fuel. I am beginning to fully appreciate how our food influences the billions of bacteria residing in our body. This is especially true of bacteria in our gut.

I introduced raw milk into my family’s diet a couple of years ago. I needed to try something. My son’s GI tract distress was intolerable–for me. I could hardly enter his room. I thought about pro-biotics and prebiotics, but was turned off by the high prices. I wanted to try something more organic. Was there something we could be eating?

INTRODUCING GOOD BACTERIA TO OUR GUT

Raw milk entered our food supply. The impact was immediate. Less gas, less bloating, less stench. I often wonder if we are more like cows than we think. Feeding cows too much grain causes them to bloat as well.

I became a devotee of Organic Pastures raw milk. I appreciate the fact that the cows graze on pasture and the cows and the milk are regularly tested. Mark McAfee is the owner and trained as a microbiologist. It seems Mark spends every waking moment heralding the benefits of healthy bacteria in our gut.

A POST PASTEURIAN WORLD

In the Pasteurian world, all bacteria is destroyed. We sterilize, pasteurize, and sanitize our food supply to our own detriment. We need to embrace a post-Pasteurian world view, especially in regards to our food supply. We can’t continue to rely on a seek and destroy orientation to the bacterial world.

Industry needs to rethink how we grow and manage our food. Assaulting the sins of mass production with massive doses of antibiotics is a mistake

Regulatory agencies need to trust science to monitor microbes, not just seek to eradicate them. Zero tolerance needs to be a thing of the past.

We all need to learn to work with the body–and the billions of bacteria that live symbiotically with us.

What we eat has a huge influence on our health and well being. The quick fix experts will redouble their efforts touting the benefits of probiotic and prebiotic supplements. They are probably a useful Band Aid, but my guess is that our overall diet counts more.

We are inundated with an obscenely processed and adulterated food supply. We need to figure out how to survive abundance. A good starting place is consuming more whole foods like beans and legumes, fresh fruits and vegetables; maybe some whole grains, but not too much; adequate protein, and enough healthy fat. We need to embrace healthy bacteria from the right kind of raw milk and fermented foods. We all need to eat closer to the earth.

Filed Under: Blog Tagged With: addiction, antibiotics, appetite, bacteria, bloating, colitis, constipation, crohn's, diarrhea, fermented food, gas, GERD, gut, hunger, immune function, inflammation, insulin resistance, microbiome, organic pastures, pasteurization, prebiotics, probiotics, raw milk, reflux, resistant starch, sugar, weight

Do “Americans Eat Too Damn Much”?

May 17, 2012 by Bonnie

David Lazarus recently wrote a diatribe scolding gluttonous Americans in the Los Angeles Times. The notion that Americans just “eat too damn much” is a popular screed. Experts weight in and determine that it is advertising and marketing to kids that is the problem. Others claim there is not enough exercise. Well yes, and no. The issue is far more complex than these solutions suggest. Here are a few thoughts I shared with Mr. Lazarus.

Dear David,

I am glad I read your column on a regular basis. You have written insightful pieces, made poignant arguments, and exposed many wrong doings. I trust you are an intelligent and thoughtful man, but your screed regarding obesity is absolutely off the rails. You faltered the minute you embraced weight as the problem and assumed that the calorie balance equation is all there is to understand about energy metabolism. You assume that if people are obese it is merely because they are too gluttonous for their own good. You couldn’t be more mistaken.

Ironically, those of us in the trenches as well as many researchers are beginning to recognize the many ways and reasons people gain fat weight preferentially. Calories are only one of many factors. There are fewer and fewer people invested in the simplistic belief that “eat less, exercise more” is the answer to the growing obesity epidemic. In fact, the people who are still believers tend to be those people who have little personal or hands on experience with weight management (and please take that literally—researchers who mostly crunch numbers and publish the articles don’t count. Talk to those of us who work with patients and clients on a one-to-one basis)

Most of my clients struggle mightily. Of course calories count, they just are not the only thing that counts. Far more impressive people than I have argued that the issue is multifaceted and very complex . These authors identify 10 putative factors that have at least the same potential to impact the obesity epidemic as the currently popular and repeated arguments re: marketing to kids and not enough exercise. Studies show that thinner children can eat more calories, sugar, refined starch, and fat than their heavier counterparts. Clearly, obesity is not merely a math problem.

In my own work, I notice significant lifestyle factors that influence energy metabolism and create an environment that makes it more difficult to utilize fat and glucose effectively for fuel.

Poor food composition and distribution
Poor food quality (often an economic issue—see Adam Drewnowski’s work for more details) that is subsidized by government farm policy. Highly refined starch, sugar and fat is far cheaper to purchase per 100 calories than fresh fruit, vegetables, and lean protein sources
A preoccupation with “safe” that destroys all bacteria, including healthy bacteria that can improve gut microbiota and immune function
A gut microbiome that is linked to greater fat synthesis secondary to poor food quality
Gut peptide secretion secondary to food intake and gut bacteria that seems to alter appetite regulation
Sleep deprivation and poor sleep hygiene that increases sugar cravings and alters appetite
Chronic pain and may other sources of stress that exacerbate insulin resistance secondary to excessive cortisol secretion (consider a society that keeps raising the bar, increasing expectations, evaporating a safety net, etc)
Long hours at work and extensive commute time that erode time and energy for physical activity; anxiety on the part of workers that if they don’t sacrifice their personal life, they will soon be out of a job
Preoccupation with (financial) success, both in school and work, that pushes aside quality of life factors
Little or no appreciation or time to adequately shop, prepare and eat whole foods. We pretend we can do it even with 10-12 hour days away from home
Poor nutrition status for women of childbearing age. We know that pre-pregnancy nutrition status and the intrauterine environment influences the offspring’s metabolic health. Babies born to mothers with gestational diabetes and other states of insulin resistance (including obesity) are much more likely to become diabetic and/or struggle with metabolism and suffer high rates of birth defects. About 50% of births are unplanned for both married women and unwed teens. This does not bode well.
Exposure to endocrine disruptors and other obesogens that influence glucose tolerance, thyroid function, and insulin sensitivity via the environment—especially secondary to plastics, pesticides, and other contaminants (95% of which reach us via our food supply)

In addition, there are fundamental societal and system issues that complicate people’s access to adequate nutrition care and support.

Little money, time or willingness to teach life skills (including cooking, shopping, menu planning, budgeting, etc) to students. Somehow the overworked parents are supposed to do it all.
Negligible resources for adequate nutrition education in K-12. It is not easier to eat well today. It was easier when all we had to worry about was getting enough. Most schools don’t teach nutrition, and if they do it is taught by someone who isn’t really educated about nutrition. The information ends up being dogmatic and rigid—not very effective. Maybe the instructor’s degree is in PE or health, biology or the like….not good enough.
Pretending primary care doctors and nurses can deliver effective nutrition counseling. Doctors don’t get much nutrition training and often demonstrate even less skill in counseling. Nurse’s get about one semester’s worth. Have you ever asked how many patients get referred to dietitians or qualified nutrition counselors even with legitimate diagnoses?
Medical nutrition therapy (MNT) is rarely covered except for diabetics and folks with renal disease. Even then, time and access to an RD is laughable. Diabetics are supposed to be effectively “managed” at one local institution with four 15 minute appointments a year. And we wonder why people are “non compliant” and “lost to follow-up”
Everyone with dyslipidemia (cholesterol problems), hypertension, inflammatory states like gout, asthma, and allergies, and even cancer is likely to have to pay for MNT out of pocket unless dietitians accept a fraction of usual billing costs (but this is nothing new—it’s just that I can’t see 8-10 people in an hour and do any good—that’s not counseling, it’s pretending that knowledge is the same as behavior and there is only one right way to eat)
Individuals struggling with obesity, disordered eating and outright eating disorders are likewise not typically covered unless they are seen within a medical setting with an MD on board. The medical model doesn’t work so well when it comes to nutrition counseling. Our process is much like the therapeutic model used by mental health practitioners.
The government’s latest position with new funding for covering obesity basically establishes the primary care MD as the gatekeeper and employer for all nutrition services. How ironic that as someone with 25 years of experience working with clients in my own practice I am now expected to have an MD set the protocol and standards for my practice. Currently I teach MD’s, nurse practitioners, physician assistants and other health providers how to effectively help patients regain metabolic health.

Despite all of this, obesity isn’t the real issue. Weight has never been an effective bio-marker for disease or surrogate for health. It is sloppy and lazy science/journalism/public policy that continues to perpetuate the myth. The real issue is metabolic health.

Filed Under: Blog Tagged With: appetite, calories, exercise, farm bill, food costs, gluttony, gut peptides, metabolism, obesity, weight

Less trans fat, number of obese stabilize. Is there a link?

February 15, 2012 by Bonnie

Last week The Center for Disease Control reported than the presence of trans fat has decreased in our blood by 58% between 2000 and 2009. The FDA mandates nutrition labels to include trans fats in packaged foods as of January, 2006.

Food manufacturers were given significant advance notice of the initiative, enough time to reformulate their products. The process of partially hydrogenating vegetables oils was invented by a German Scientist at the turn of the century. Crisco was on the shelf with recipe books in 1911. The FDA determined partially hydrogenated fats were “generally regarded as safe” (GRAS status) in 1958.

CELEBRATING THE PROBLEM

Americans were admonished to switch to margarine in the 1970′s in a misguided effort to reduce risk of heart disease. An appalling lack of science and an overabundance of hubris spurred a revolution in processed foods. I remember reading full page ads in the LA Times, exhorting companies to abandon the saturated fats of the day. Soon “healthier” vegetable oils were replacing palm and coconut oil as well as butter, lard and other saturated fats. What a mess.

Partially hydrogenated fats were found in suspected places and unsuspected places. Ironically the biggest source of trans fat came from bread, crackers and bakery items–about 40% of all trans fat in the food supply. The partial hydrogenation of vegetable oil allowed these products to last longer on the shelf.

SOURCES OF TRANS FATS

Ironically, french fries and other fried foods contributed far less trans fat than bakery items. Unfortunately, the public health bias regarding fast food meant undue attention was placed on that sector.

My husband works in the food industry, when I called Cargill and Archer Daniel Midland and asked them how much liquid shortening was sold with partially hydrogenated vegetable oil, the answer was blunt and direct: 99%. Practically every restaurant, cafeteria and food service institution in America was using liquid fry oil with partially hydrogenated fat, regardless of whether you were talking about the local diner, the restaurant of a five star hotel or your community schools and hospital.

THE TROUBLE WITH TRANS FATS

Over time researchers started to question the GRAS status of trans fats. While FDA scientists didn’t start addressing the issue until after 2000, industry scientists were already aware that there was an problem in the early 1990′s.

One veterinarian from Wake Forest University ran a study on monkeys, giving both the experimental and control groups the same number of calories, the same amount of fat and the same amount of activity. The only difference was the type of fat used in their chow. The experimental monkeys were fed 7% of their calories from trans fats. Olive oil made up the rest of the fat and 100% of the fat in the control group.

After 8 years, the control monkeys gained 1.2% of their body weight. The experimental monkeys gained 6.8%. If we try to translate that data into human terms, this would be equivalent to a 130 pound human female gaining 10# of fat just because the she ate food containing manufactured trans fat. And most of it would be in her belly.

LABELING TRANS FATS

Labeling trans fats in foods set up a firestorm. Mostly it has been a good thing. The one unfortunate truth is that the FDA allows manufacturers to state “O” trans fats when in fact a product has less than 0.5 gm of trans fat per serving. The American Heart Association recommends no more than 2.5 grams of trans fat per day.

Trans fats on food labels

It is quite easy to eat more than “one serving” of anything. How many people eat just one ounce of a muffin? Most commercial muffins, cookies, and other bakery items are eaten in 2, 4, and 6 ounce portions.

It is important to note that not all trans fat is the same. Ruminant animals (cows and the like) also produce naturally occurring trans fats. These trans fats are actually thought to be health promoting. It is the artificially manufactured trans fats from partially hydrogenated vegetable oils that scientists believe to be the problem.

LESS TRANS FAT TODAY AND OBESITY TRENDS HAVE FLAT LINED

Since 2006, sales of foods adulterated with trans fats have plummeted. The CDC report that we carry less trans fat is our blood underscores the consumer response to labeling trans fats. Just last week Shari Roan of the LA Times reported that obesity rates are leveling off. The usual experts touted how all our public health efforts are starting to work. I’m not so sure.

For the most part, public health efforts are wishful thinking guided by some science and driven by the need to do something. Telling people to eat less fat didn’t work out so well. Telling people to avoid saturated fat didn’t work out so well. Neither has the tired and overused, “eat less, exercise more.”

But I bet reducing trans fat in the food supply maybe one effort that has really paid off. I suspect eating less trans fat has a whole lot to do with obesity rates leveling off. How do you reduce partially hydrogenated (trans) fats in your diet?

Filed Under: Blog Tagged With: Archer Daniel Midland, cafeteria, Cargill, CDC, fast food, fat, FDA, fried food, GRAS, hospital, LA Times, obesity, partially hydrogernated fats, public health, restaurants, schools, trans fat, weight

COPING WITH BOREDOM: How much do you eat when you’re not hungry?

January 19, 2012 by

In a recent study, twenty five percent of British office workers claimed to be bored and used chocolate or coffee to cope. They also tended to use alcohol at the end of the day.

Boredom is uncomfortable. It is much more fun to be engaged in a preferred activity or spending time in good company. Food and drink provide immediate gratification. Both are relatively cheap, available 24/7, can be consumed alone or with others, and are not illegal.

SELF SOOTHING WITH FOOD AND DRINK

Businesses including entertainment, technology and law firms commonly stock roomfuls of snacks and treats, effectively coercing workers to work longer hours and right through lunch. Other workers pay for their gustatory entertainment at cafeterias, vending machines or upscale convenience stores found in high rise office buildings. Food and drink would be ideal coping mechanisms if it weren’t for those pesky side effects when you consume more than your body needs or can handle.

Ideally we eat delicious and satisfying food when we are hungry and stop when we are satisfied. This is food’s rightful place. Without hunger, entertaining ourselves with food opens Pandora’s Box.

OVER EATING, OVER DRINKING, INFLAMMATION

Eating more than we need triggers a cascade of metabolic consequences that increase inflammation. To add insult to injury, most popular snack foods contain one or more problematic ingredients known to increase makes things worse all by themselves: excessive fat–especially trans fats; refined starch, sugar and high fructose corn syrup; sodium and alcohol.

Inflammation is linked with everything from heart disease, diabetes and cancer to autoimmune disease states and Alzheimer’s. This is true whether weight is normal or excessive. People who don’t gain excessive fat weight eating poorly do not “get away with it” in the long run.

How can people step away from using refined starch, sugar, caffeine or alcohol to cope with boredom? What are your favorite ways to self soothe without using food?

Filed Under: Blog Tagged With: Boredom, coffee, diabetes, drinking, eating, inflammation, office, office workers, weight