Dispelling nutrition myths, ranting, and occasionally, raving


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To keto or not to keto

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I feel like there’s one thing missing from a lot of the discussion about the keto diet (and similar extreme diets, really). Everyone talks a lot about whether or not it “works” with proponents on both sides, research supporting both sides, arguing that it does or doesn’t work for weight loss. The problem with this is the assumption that weight loss is the most important feature of a good diet. It’s not. You can lose weight eating lots of things that are not going to provide you with the nutrients you need. Weight loss is not the most important thing for health, despite what the media, the “wellness” industry, society, and even many health care professionals have lead us to believe.

Just because you feel good on a ketogenic diet and are losing weight doesn’t mean that it’s a good idea. As a dietitian, this is something that I really struggle with. It’s our job to support people. We can tell them that keto is a difficult diet to follow, that it may not be advisable, but when it comes down to it, they decide if it’s something they want to pursue or not. And if they do decide to pursue it, we can’t say “well, good luck, I wash my hands of you”. We have to help them undertake it in as healthy a way as possible. Which kind of blows my mind (and makes me glad that I don’t work in a counselling role) because if someone came to us with an eating disorder we wouldn’t support them in that. How can it be ethical for us to support people in following a diet that may cause them harm?

A little history of keto: the ketogenic diet originated as a treatment for epilepsy in children in the 1920s. It was intended to mimic the effects of fasting through the generation of ketones. In recent years this concept has caught on with people desiring to lose weight. After all, if ketones are produced during fasting, then if a specific diet can promote the production of ketones, it may also lead to weight loss. Not illogical. In some children with epilepsy who do not experience a reduction in seizures with medications, the ketogenic diet can be an effective treatment. However, there are potential side-effects.

A few long-term studies (1, 2) have looked at the effects of the ketogenic diet in children and have found such side-effects as: kidney stones, slowed growth, dyslipidemia, and fractures. There are also short-term risks (2, 3, 4) associated with the diet in children with epilepsy including: acidosis, hypoglycemia, gastrointestinal distress (including vomiting, constipation, diarrhoea, and abdominal pain) dehydration, hypoproteinemia, and lethargy. All of these studies have found low long-term adherence among children. There are many reasons for this: some children see improvement in symptoms, even after discontinuing the diet, others find it difficult to adhere to the diet, for some it’s not effective.

Of course, adults who wish to lose weight are not the same as children who have epilepsy. It’s hard to say if slowed growth in children would have a similar counterpart in an adult. However, many of the short-term side effects may be seen in adults, as may some of the other long-term side effects. In addition, there is potential for nutrient deficiencies when following such a restricted diet. Unfortunately, we don’t have research into the long-term effects of a ketogenic diet on adults using it for weight loss. We have some short-term studies that primarily look at it from the standpoint of whether or not it’s an effective weight loss diet. Maybe it’s perfectly safe, but maybe it’s not. Given that the vast majority of people who lose weight on the diet end up regaining it, and often more, is it really worth taking that risk? By following a keto diet you’re basically enrolling yourself in an uncontrolled experiment.

I think it would be interesting to know what the long-term effects of a ketogenic diet for weight loss are in adults. What I’d really like to know though is why we have become so obsessed with being thin that we are willing to adopt disordered eating habits at the expense of other aspects of our health and well-being. Why is it when we talk about a diet “working” we de facto mean weight loss? Why have we come to value weight loss over every other indicator of health? Why can’t we just value ourselves enough to properly nourish our bodies?


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Whole Life Challenge review

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You know what I’m sick of? Engineers and people with zero nutrition education making claims that you can “biohack” your life, undermining dietitians, and giving one-size-fits all nutrition advice. This rant seems appropriate coming on the heels of my post about the carnivore diet.

Earlier this summer my brother asked for my thoughts about this “Whole Life Challenge” that a bunch of people in his office were doing. He was a little sceptical about the nutrition advice they were providing and wanted to know my thoughts as a registered dietitian.

My first question was, “who is behind this challenge?” Well, we’ve got the founders: Andy who has a background in sales and engineering (quelle surprise) who then opened a crossfit gym and Michael who was a coach and manager at a crossfit gym, and has a degree in philosophy and culinary arts. Well, at least he’s got a little knowledge of food in there but as most know, culinary arts and dietetics are woefully disconnected professions with chefs learning little to nothing about nutrition. The remainder of the team is comprised of the CEO, social media, web development, content manager, corporate relations, a couple of customer service reps, chief technology officer, and public relations. There is absolutely no one working for this enterprise that has any background in nutrition or health. Sigh. 

At a glance, the “challenge” doesn’t look so bad. The idea is to work on seven daily habits over the course of six weeks. You get points for completing each of the daily habits and you’re supposed to play with a team (the more people playing the more money they make this will help “foster success”). The habits are as follows: nutrition, exercise, mobilize, sleep, hydrate, well-being, and reflect. Many of these are areas that most of us could stand to improve on. Of course, I’d like to reiterate that the people who created this challenge have zero education pertaining to any of these topics. Cost is $39 US per player.

Unfortunately, you have to pay to play so I can’t access all of the materials available to players, including the nutrition plans. Fortunately, I have the inside scoop ;) and was able to view the nutrition material. They’ve created three levels with the highest being the “performance level”. This level is for those who, “already have good eating habits that you just want to fine tune, have athletic or performance-related goals, or have a pressing health or inflammation condition that you’d like to address”. The level below that is the “lifestyle level” which is, “A good choice if you are looking for a long-term lifestyle nutrition program. This is a great start to a sustainable practice of living a healthy lifestyle”. The easiest level is “kick start” which is supposedly, “a great place to start if you’re new to the health and fitness game and need to make the most important tweaks to get yourself started in the right direction”.

At each level of the plan you’re given a list of foods that are “compliant” and “non-compliant”. The higher the level, the fewer the foods that are compliant. How did they determine which foods are “compliant” and which are “non-compliant”? Excellent question. I have no idea other than the statement they make at the top of the charts: “When you see (*) next to a food, it indicates the food is compliant but should be eaten in moderation, as there are potentially negative effects from overconsumption”. I assume that this means that they believe there are negative effects from consumption of “non-compliant” foods. What these negative effects are is anyone’s guess. Maybe weight gain? Inflammation? Enjoyment of life? The non-compliant foods for the “performance level” are: deli or processed meats, soy, corn, white potatoes, soybeans, taro, yucca, beans and other legumes, dried fruit with added sugar, peanuts, peanut butter, hydrogenated oil, industrial vegetable and seed oils, every grain and grain product, alcohol, soda (diet or regular), juice, all dairy (except butter), the only snack foods allowed are baked sweet potato fries or chips and baked vegetable chips. Yum yum. To be fair, they do say that this diet would be difficult to maintain long-term and “maybe not even necessary”. Yeah, no shit.

Just for fun, and your reading pleasure, my brother endeavoured to follow this diet for a few days. My brother is a prolific runner, he’s in his third year of a running streak and he’s fast. He eats a balanced and varied diet and enjoys the occasional beer; a candidate for the “performance level” if there ever was one. Unfortunately, he came down with a cold at the same time so his report was: “my lack of energy could have been the diet or being sick”. N of 1, inconclusive.

That being said, while this diet might work for some, it’s probably not the best diet for most endurance athletes. It can be very difficult to obtain sufficient nutrients and calories and attain peak performance on such a limited diet. Also, beans and legumes and whole grains are full of good nutrients as well as being affordable. Any non-medical diet that tells you to eliminate all of these foods is unlikely to be sustainable or healthy in the long-run, particularly for those who engage in long runs (sorry, not sorry).

Six weeks isn’t all that long and when people are working in a group challenge there’s more incentive to stick to a plan than there would be on their own. There’s also minimal risk of nutrient deficiencies being a serious concern over such a short time frame. However, because this challenge is framed as a short-term undertaking and the diet plans aren’t easily sustained, I worry that this will encourage weight cycling in participants (which may actually be more harmful than maintaining a higher weight long-term) and discourage long-term adoption of healthy behaviours. If you’re only adopting these “habits” for six weeks to win a challenge and it’s a major change from your usual lifestyle I can imagine that at the completion most people celebrate finishing by ditching all the “habits”. It would be interesting to see research on participants of a challenge like this.

This plan is also very prescriptive. Apparently I should be drinking 37 ounces of water a day. There is no mention of drinking to thirst here or adjusting intake based on physical activity, temperature, or other fluid intake. You are not learning to listen to your body on a plan like this. There is no allowance for individual differences or personal preferences. Compliant foods equate to “good” and non-compliant equate to “bad”. This reinforces the false moralistic attitude that many people have about food. It also fails to consider that we eat for many different reasons and that taking pleasure in food and enjoying food socially are important aspects of eating. Framing healthy eating as being complicated and unpleasant only serves to make people adopt an all-or-nothing mindset toward a (perceived) healthy diet. Winning at this challenge may only set you up for failure when it’s over.


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Why science is failing

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After my fellow dietitian Abby Langer wrote this article for Self, which I personally felt was quite considered and rather generous to the carnivore movement, I noticed a commonality among many of the people spewing abuse and vitriol (does an all-meat diet make you exceptionally angry?) toward her, and RDs in general. Any guesses? It was that many of them were engineers. I’m not sure what’s up with that. However, I can tell you that they are far more confident in their belief in the magic of the carnivore diet than I am in probably anything.

Then I was listening to StartUp podcast and something clicked. This season they’re following what’s called a “church plant” which is people trying to start new churches. On the last episode they were talking to a researcher who said that membership in all Christian churches in North America is declining, except for at evangelical churches. The reason for that? The certainty the evangelical church provides. Unlike other churches where there may be grey areas, things left up to interpretation, the evangelical church has definitive answers. And people like certainty. In religion and in nutrition.

You’ve probably heard the comparison of certain dietary beliefs to religious beliefs before. It’s nothing new. People attach their sense of self to a religious or dietary belief. They’re vegan, paleo, vegetarian, carnivore, catholic, or muslim. In the realm of diets, dietitians are agnostic. In the realm of medicine, Western doctors are agnostic. A great deal of the time, science is agnostic. We constantly question our beliefs and change them as new evidence comes to light. When someone asks is corn good for me we inwardly cringe because there are so many ways to answer that question and they all start with “it depends”. The carnivores are the evangelicals of the dietary world. They have all the answers with the utmost certainty. And how can someone who’s desperate to find a diet that will cure what ails them not be enticed by that confidence when faced with dietitians and doctors who are saying “let’s try this first and if that doesn’t work then we’ll try this” and on and on. We don’t offer a one-size-fits-all approach. We offer tailoring to help individuals find the way of eating that fits them best.

If you want certainty without evidence then you can find all the advice you want, and then some, from carnivorous engineers on twitter. If you’d rather have uncertainty and a little variety in your diet then find yourself a dietitian.


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A smile doesn’t hide your weight bias

 

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I completed an online course on weight bias and stigma for healthcare professionals last week. There was quite a bit that was good but there were a couple of things that rubbed me the wrong way.

If you’re not already aware Obesity Canada states that, “weight bias refers to negative attitudes and views about obesity and about people with obesity. Weight stigma refers to social stereotypes and misconceptions about obesity. These social stereotypes and misconceptions include beliefs that  people with obesity are lazy, awkward, sloppy, non-compliant, unintelligent, unsuccessful and lacking self-discipline or self-control.” 

Weight bias and stigma can cause significant harm to fat people. In fact, they likely cause more damage to people than carrying extra weight itself does.

The course I took was very good about making this clear and provided the facts as well as showing how harmful weight bias can be to patients. However, there was a video with some experts that I felt undermined the message. Here are the quotes that bothered me:

“If weight loss was easy we wouldn’t have the current obesity epidemic that we have.” – Director of Research and Anti-Stigma Initiatives at the Yale Rudd Center

“People think that for someone who’s overweight all they need to lose weight is some self-control and trying harder to eat less and exercise more. If that only worked we wouldn’t have the problem that we have today. The causes of obesity are very complex…” – Director of Research and School Programs at the Yale Rudd Center

The Yale Rudd Center is well-regarded for their work in reducing weight stigma and both of these individuals quoted above are prominent in the field. At first glance what they’ve said seems innocuous. However, the fact that this was a course intended to combat weight stigma, the experts are saying that obesity is an “epidemic” and a “problem” runs counter to the message they’re trying to convey. It just goes to show how deeply ingrained weight bias is when the very experts trying to counter it are inadvertently perpetuating it. When you say that obesity is a problem then you are saying that fat people are a problem. And I don’t see how that’s not stigmatizing.

The other problem I had with the course were the case scenario videos they shared. There would be one video where staff and medical professionals were rude and unprofessional to patients regarding their weight. Then they would show a video that was intended to show a positive interaction. Really the only differences in the “good” videos were that the healthcare professional was all smiles and asked the patient if they could talk about their weight before advising behaviour change under the guise of promoting healthy behaviours rather than telling them directly to lose weight. To me, the message was the same, it was “you need to lose weight” delivered with a smile rather than scorn. There was still no looking at overall health to determine if weight loss was actually warranted, there was still no consideration of other causes of the presenting ailments, and there was still no recognition that simply telling people to eat healthier and move more (especially without first determining what their current lifestyle is like) is not an effective way to get people to lose weight.

Overall, I felt that the message of the importance of not perpetuating weight bias was lost when all the healthcare professionals were still delivering the message to their patients that they should lose weight. And yes, some people can benefit from losing some weight, but this should be determined with appropriate assessment and then weight management options need to be appropriately discussed with the patient. Simply telling someone, on the basis of their BMI, to eat less and move more with a smile is not helpful.

If you do happen to know of a good online weight bias course please let me know as I’m still looking!


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If you’re cheating on your diet, then you should probably break-up with it

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Yes, the above post is undoubtedly very cute. Using emojis is a fun way to make your point. However, I would argue that if you are struggling with your weight that you should actually reverse the suggestion by Dr Nadolsky.

I’m not saying, eat unhealthy food all day every day. I’m saying, take some of those “treat” foods from the weekend and enjoy them whenever you feel like it. Something more along these lines:

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If you’re struggling with your weight and you’re eating super healthy through the week and then you “undo” all your hard work by eating a bunch of crap on the weekend your problem is not the weekend. Your problem is the week. If your workweek diet is very restrictive and doesn’t allow room for treats, or carbs, or entire food groups, then it’s not a sustainable way of eating. If you feel deprived during the week, then it’s not a sustainable way of eating. If you can’t continue to eat the way you eat during the week through the weekend, then it’s not a sustainable way of eating. If your diet through the week is devoid of pleasure, then it’s not a sustainable way of eating. If you’re cheating on your diet whether it be for one day a week, or all weekend, then you should probably break-up with it.

Regardless of your weight, your diet should be one that you enjoy. That provides you with nourishment and pleasure. You should be able to enjoy your food every damn day of the week.